GW1--04524_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 1a >zzma„ h oora ,
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft. 1 '
NC Well Contractor Certification Number ZIS COI'CEReCASING(to muiitsiilitiiiiigOr 1Nk,R;{iYiallc liKM—M"
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt• 70 ft. 6.25 in• #21 Pvc
Company Name ii1YG.t7RTlIB11r(r(Reb It Chili dosed lotip `: r�� '�'�`16.,1^fNER.CAS
NRH-155W HROM 'CO DIAME'lFR 'THICKNESS MATERIAL2.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): 3A17"sSCREENA mp m.- . .,w "t '
Water Supply Well: FROM TO DIAMETER SLOT SIZE . THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Publie
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in.
❑IndusttiaUCommercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Oh-ligation 0 ft. 20 ft• Bentonite Pumped
Non-Water Supply Well:
ft. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery ,
Injection Well: ft. ft.
❑Aquifer Recharge El Groundwater Remediation 1014Al'li/GRAtjEL'PACK(It:appli tile3 VE i ". t ;
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ID Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.*`1)1fI1Ii11VO1: Cr'.TatiaclfliaBitianaiiiiii 's'ifneccssarY"�71 �..a›
❑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. 70 ft. OVER BURDEN
5-22-2023 70 ft• 405 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. rt. " y i S „•41
5a.Well Location: ft. ft. t""',-.7.:
,, rs.S-•,'1„,a Zi R,_ .,,,
Michael Delucas ft. ft. JI)I i ; 2023
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Buckeye Branch Drive Clyde, NC 28721 a, ft. inrn.,+er,+:i�al ?,<::..,447.4 g tuna
,As s5
Physical Address,City,and Zip `zZinR''tiiARtZBN:h,<,,, ';',k
Haywood 8741-45-8882 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 5-24-2023
Signature of Cettifi ell Contractor Date
6.is(are)the well(s): OPermanent or OTemporary By signing this horns,1 hereby eertify'that the nvell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or END copy of this record has been provided to the well owner.
If this is a repair.fill out known well construction infornnation and explain the nature of the
repair under#21 remark's 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: 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 wells list all depths if di/Jerent(example-G3(al 00'and 24;100') construction to the following:
10.Static water level below top of casing: 1`� (ft) Division of Water Resources,Information Processing Unit,
If rioter 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) 60 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form,within 30 days of completion of
13b.Disinfection type: Amount: 35 well construction to the county health department of the county where
constructed. 1
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013