GW1--03587_Well Construction - GW1_20230522

WELL CONSTRUCTION RECORD For hitemal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers °71i1:O�1`'ATEIi�Z(: i'
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft.
NC Well Contractor Certification Number l5#OU CERGASIPt for:inniti casedivetis:fSIZ 4tNEit=:if` Ileabfe
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. 58 e. 61/8 i #188 Steel
I6liiVER CAStlYt51n01 I ItB111C etl erinatctosedFlijo
Company Name - -
370446-3 FROM r0 DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: rt• ft. in.
List all applicable vs-ell permits(i.e.County,State,Variance,Injection,etc.) ft. ft: in.
3.Well Use(check well use): IRA
s
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
ft. ft. in.
❑Agricultural ❑Mutlicipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) Z,40GROU7
FROM TO MATERIAL EMPLACEMENT METHOD tL AMOUNT
❑hTi ation 0 rt. 20 ft. Bentonite Pumped
Non-Water Supply Well:
rt. rt. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: t't. fL
❑Aquifer Recharge ❑Groundwater Remediation 9:5ANA1l;RAYEL.PACKl ifa Itestle� �
[]Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
Ct. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
2b'-D111MN"e r4G�(ait—5a dCtrona tsifilecessa"
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color•hardness,soillzwk type. rain size,etc.)
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 rt' 58 fr OVER BURDEN
4.Date Well(s)Completed: 4-20-2023 well ID# 58 e, 185 fr GRANITE
ft. ft.
5a.Well Location:
Sherry Ashley Metcalf Cogdill
Facility/Owner Name Facility ID#(ifapplicable) ft, ft.
1212 Holland Creek Road Mars Hill, NC 28754 �,n
Physical Address,City,and Zip 2•t It jVIARK � _ := `
Madison 9860-70-1147 Well Was Self Certified
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N 4-25-2023
Signature of Cat@ ell Contractor Dale
6.is(are)the well(s): RPermanent or ❑Temporary By signing this ftnni,I herehv cerdfy that the well(s) Iras(nere)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0300 11'ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No copy of this record has been provided to the well owner.
If this is a repair,fill out knuim well construction infonnatiou cold explain Nie tranire of the
repair under#21 remark-section or on the back oJ'thisJornt. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 tit 2 00'and 2Ga,100) construction to the following:
10.Static water level below top of casing: 60 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing.use•'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
ROTARY 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 Method of test: RIG
24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
PILLS
13b.Disinfection type: Amount• 20 well construction to the county health department of the county where
constructed.
I
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013