GW1--04490_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 Sawyers iixWAVEitiZti s� �. T W i .
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number • :STOUTEIWASt1Y .{forimnitl ca`s`ed tis)diitiNER;{iP3Altca6le) =:A
FROM TO DIAMETER THICKNESS 1sIATF.Rr.4r.
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 72 ft• 6.25 in. #21 PVC
Company Name «t0:INN-Cfe AS1NG"'tOIZTUi3U11G`{(ea)hirmatrclosetl'too � W `
248439-2 FROM TO DIAMETER THICKNESS MATERI.AI.
2.Well Construction Permit 11: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft ft. in - —
3.Well Use(check well use): 91TiSC?REL•N• W ;°i A. ,7:
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ElResidential WaterSupply(single) ft. ft. in.
❑IndustriallCommercial ❑Residential Water Supply(shared) 18GROUT Y° . x �" �, • r s r, ;, s'e ' n.01
FROM TO MATERIAL EMPLACEMENT METHOD&.AMOUNT
❑hTigation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monicoring ❑Recovery ft. ft. Cap top with Bentonite chips
injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation :19ySANE/GRAVEi.=P<AGK:(it.applieatile) `a VAM . ' ,';''
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO hIATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology El Subsidence Control
52U,§1JRltirIN ''Ia'OQi(inch„naiftfi@inriheef"s liiecessaii/W' . u`
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 72 ft. OVER BURDEN
6-17-2023 72 ft. 305 ft• GRANITE
4,Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ��
rt, ft. ^r e ` s
Scott Hege ft. ft. ':L rs> Cm'12
Facility/Owner Name Facility ID#(if applicable) ft. ft. J U_
Huggain Drive Mars Hill, NC 28754 y 7_i1?�
ft. ft.
Physical Address,City,and Zip Y v f t Ir "' �'cc -�1 i i:s 'tin*
i t:REtlVARKS .c. I £ ,; k�AVIA�,M W .
Madison 9737-45-3575 `• ��4.:
This well was self certified
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: mixiii .. 4..........._. •_22.Cetiticon:
' (if well field,one lat/long is sufficient)
N W06/21/2023
Well Contract Date
b.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo 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#21 remarks section or on the back of This form. 23.Site diagram or additional well details:
1 You may use the hack of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY will:the same 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 if different(example-3 tit 00'and 24400') construction to the following:
10.Static water level below top of casing: 20 (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 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
RIG 24c.For Water Supply Sr Injection Wells:
13a.Yield(gpm) 15 Method of test:
PILLS Also submit one copy of this form'within 30 days of completion of
136.Disinfection type: Amount: 30 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013