GW1--04527_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:
Kol by Mitchell Sawyers 14:AvATI:wZ"ng ma` mp 'im-, _ iow
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft. '
NC Well Contractor Certification Number I5 0.1lTEleCMIN (focmuitf cased4+.tl&Mit. iNgft4ifvappltcafilej ...
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 75 ft• 6.25 in. #21 Pvc
Company Name 101NNERCAS-1404 RTUBU9 jt'eofliehifii elasQd-tgoi � ;A: ' i r ,� z'
JCH-040W ...0,. 10 DIAMETER THICKNESS MIATERIAI,
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): 1T SCzREEN ' W&'x*, " 5 X 'I.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ifi'GROUT` *-11-' s `< .,t°- `
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lmgation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft. Cap Top with Bentonite Chips
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation -"I9:`SAND%GRA'VELPPACIOitif"°l (im telfAA e:� IMOW10410
❑Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD❑
ft. ft.
❑Aquifer Test El Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
PEU TtititilvG>l{ia,(a'ilaclail`dittottltrs"Iteetsifnecessary) € 1i
❑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. 75 ft. OVER BURDEN
5-19-2023 , 75 ft, 205 ft• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft. ';;r,==, e L I 'ti{ :)
Keith & Shari Allen ft. ft. s'-�r�
q(�q
Facility/Owner Name Facility ID# ; 202(if applicable) ft. ft. JUL 1 • 3
Off Ivy Creek Drive Clyde Clyde, NC 28721 ft. ft.
Physical Address,City,and Zip 41'Rk'i4IARKM, z --aVOW -K4 ii " ...
Haywood 8648-61-8981 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 ofCettifi ell Contractor s Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby certify that die well(s)was(were)constructed in accordance
with 1 SA 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 ONo 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:
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: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi/jerent(example-3 dl 00'and 2(4+100') construction to the following:
Division of Water Resources,Information Processing Unit,
lb.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 Infection 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
15 RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
25
Also submit one copy of this form within 30 days of completion of
PILLS
13b.Disinfection type: Amount: 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