GW1--03588_Well Construction - GW1_20230522

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers FROM D
TO D����; DESCRIPTION
FROM RI PTION
Well Contractor Name ft. ft.
4471-A
NC Well Contractor Certification Number
f521 'vLfi" �lYti OITeiti C8$t1. � 't3i[t't lliltf if I(Calile ..
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 58 ft. 6.25 in. #21 PVC
Company Name 16YNbttz $1NG iJR t t). t miit'elosed loii
362503-2 FROM TO DIAMETER 'THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public tr ft• in.
❑Geothermal(Heating/Cooling Supply) ©Residential Water Supply(single) tt. ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) g` U .... �
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation Non-Water Supply well: � ft. 20 ft. Bentonite Pumped
❑Monitoring ❑Recovery et' ft. Cap Top with Bentonite Chips
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation 19" IY1i, E1 PAI
❑Aquifer Storage and Recovery El Salinity Barrier FROM To MATER1A1, E51PLACEMENT IVIETHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft ft.
❑Experimental Technology ❑Subsidence Control
T- x
-�UEx attae"ndrlrt% "9feeessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sollfrock type. ram size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 tt• 58 OVER BURDEN
4-18-2023 58 ft- 685 ft. GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location:
Jeffery & Terri Rice
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
147 Woolyshot Branch Road Hot Springs, NC 28743
Physical Address,City,and Zip r err.
u21,RSt4R1Z ,
Madison 8757-82-8583 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 0C4-20-2023
Signature of Certifi ell Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary y g f f' (� (were)B signing this onto./hereby certi Ntut the wells coos were constructed in accordance
with 15A NCAC 02C.0100 or 1 sA NCAC 02C.0200 Nell Construction Standat•ds 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.Jill out knoxn well conaTruction information and explain the nature of the
repair under#21 remarks,section or on the back oJ'this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. G SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: V 85 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(exampl dte-3 00'and 2(a.100') construction to the following:
10.Static water level below top of casing: 80 (ft,) Division of Water Resources,Information Processing Unit,
Ifuuter 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) 5 Method of test- RIG 24c.For Water Supply&Injection!Wells:
PILLS Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: Amount: 35 well construction to the county health department of the county where
constructed.
Fore GW-1 North Carolina Department of Enviromneut and Natural Resources—Division of Water Resources Revised August 2013