GW1--04494_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 1'd `'ATErtzxll s . •.
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ' ft.
NC Well Contractor Certification Number ' 15 ltilltR'CASI6tatfar'm iltl itied4s 111 OR 11NSR{f a plicapte �N'
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 tt• 76 ft. 6.25 m• #21 PVC
Company Name MI6 1N1V€RYC iSt1YG URaT.t3BihG{Rep). tmal'closed 160p) ' :.ate;.moo x
063422-S FROM DIAMETER 'THICKNESS MATERIAL.
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,In/ectio n,etc.) ft. ft. in.
3.Well Use(check well use): 17 SCREENA,,,.".SWWa.k a 9 W „�1 „ - °"
Water Supply,Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
R. ft. in.
❑Geothermal((Heating/Cooling Supply) gResidential Water Supply(single)❑IndustriallCommercial ❑Residential Water Supply(shared) tg OROUT:,, , '' a � a '- .41 , u
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑iITI ption 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery It. ft. Cap Top with Bentonite Chips
Injection Well: ft. fL
❑Aquifer Recharge ❑Groundwater Remediation 49Si1NDlGRAYE>;PACIC(if applici+tjle} Y, A ' , ,., >
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery El Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
!•205D1211.IN011Datattachiiddiaiii`sheetsifmcessa> aX ;. :
❑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. 76 ft. OVER BURDEN
6-6-2023 76 ff• 405 ff• GRANITE
4.Date Well(s)Completed: Well 110
ft. ft.
5a.Well Location: ft. ft. t*';`r ,,ii_ r F .r
.z '`♦j i 'y
Thomas Doozan �` .
ft. ft.
Facility/Owner Name Facility I D#(if applicable)
ft. ft. JUL 1 : 2023
Tellico Road Franklin, NC 28734 ft. ft.
Physical Address,City,and Zip IDS73 I r..;i
21?REMARKS ;° '- � +t,. rx. �- ^d .:,
Macon 6558973052 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 W 06/05/2023
Signature ofCettifi ell Contractor Date
6.is(are)the well(s): CIPermanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or J5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided to the well msner.
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:
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. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:405 (ft.) 24a. For All Wells: Submit this,form within 30 days of completion of well
For multiple welts list all depths if different(example- dl 3 00'and 2(ur100') construction to the following:
10.Static water level below top of casing: 80 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
H.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.c.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) I 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: 35 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