GW1--04486_Well Construction - GW1_20230713

WELL CONSTRUCTION RECORD For Internal Use ONLY: '
This form can be used for single or multiple wells
1.Well Contractor information:
Kolby Mitchell'Sawyers 14.WATERGOrNES .w r _ r
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number
tIS:OUTER<CASING,(forniulti-cased'ivell$)ORLiNER(ifap lieable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS &SON WELL & PUMP INC +1 ft• 98 ft. 6.25 in. #21 PVC
Company Name I6.:INNER CASING OR''TUBING(ae ithes'mai cloned loop)„ ,
89132-2 FROM TO DIAMETER TIIICKNFSS MATERIAL
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2.Well Construction Permit#: 8 J 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 SIRE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
ft. ft. in.(Heating/Cooling Supply) El Residential Water Supply(sin le)
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM r.i - MATERIAL EMPLACEMENT METIIOD&AMOUNT
❑Irrigation 0 ft' 20 ft. Bentonite Pumped
Non-Water Supply Well: ft. rt.
❑Monitoring ❑Recovery Cap Top with Bentonite Chips
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation '19.SAND/GRAVEL•PACK(if applicable) ..,
FROM TO MATERIAL EMPLACEMENT METHOD
-
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DIitLLiNG LOG(attach-additionaTsheetsif:necessary) - ...
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soli/rock type,grain size.etc.)
DGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 98 ft• OVER BURDEN
4.Date Well(s)Completed: 06/16/2023 Well ID# 98 ft• 305 fit• GRANITE
ft. ft. '
5a.Well Location:
Tyler& Cheyenne Ball ft. ft. `— - kj
Facility/Owner Name Facility 1D#(if applicable) ft. ft. JUL j 2023
Bob McClure Road, Marshall 28753 ft. • I.
__ ,
Physical Address,City,and Zip Ins
?21t-REMARKS.`,-:`. ".:'. ra 3 LC.><:
Madison 8798-60-55e1/e798-e0 asss This well was self certifier '' - 3'"
County Parcel Identification No.(PM)
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Sb-Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:(if well field,one lat/long is sufficient)
N w 06/20/2023
Signature ofCenift Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary
By signing this form,I hereby certtlY that the walks)was(were)constructed in accordance
with ISA NCAC 02C.0100 or I5A NCAC 02C.0200 Well 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 known well construction information and explain the nature of the
repair under#2l remarks section or on the back of 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
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-wafer.supple wells ONLY with the saute construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi different(erample-3@200'and 2E01001 construction to the following:
Division of Water Resources,Information Processing Unit,10.Static water level below top of casing: 30 (ft.)
If water level is above casing,use'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For injection 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
cgp ) 7 RIG 24c.For Water Supply&Injection Wells:
13a.Yield m Method of test:
PILLS Also submit one copy of this fortis within 30 days of completion of
13b.Disinfection type: Amount: 20 well construction to the county health department of the county where
constructed.
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Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013