GW1--05628_Well Construction - GW1_20240916

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
• 1.Well Contractor Information:
Derrick Heath Sawyers A4Avxrtgzosfgsmmommmmgmtmgmm;•mmgmmm
FROM TODESCRIPTION
Well Contractor Name ft. ft.
2436-A ft. ft. . I
NC Well Contractor Certification Number .SA TER ASIN tfor rtuliVit tfwells}OR DINE i fif ap i abte)i`: .... ....
FROM TO DIAMETER! THICKNESS MATERIAL
CLYDE SAWYERS &SON WELL & PUMP INC +1 ft. 67 ft. 6.25 I,, !in, #21 PVC
\16l IN..........NG ORTLtBJNG41;eatherm aiclosed-loop)= s
Company Name .--
,
364503-3 FROM '1'0 DIAMETER THICKNESS SIATItRIAI.
2.Well Construction Permit#: ft ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in•
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- 3.Well Use(check well use): 17.SCREElrf
Water Supply Well: FROM TO ' , DIAMETER SLOT SIZE THICKNESS MATERIAL
. ft. ft. in:
❑Agricultural ❑Municipal/Public
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single)
ft. ft. in.
� � g PP Y) PP Y g
❑lndustrial/Commercial ❑Residential Water Supply(shared)
..'[8 GROUT......:_ z -- .. ...
FROM TO MATERIAL F.MPLACEMFNT METHOD&.AMOUNT
❑irrigation 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 ❑GroundwaterRemediation .19.iSAND/GRAVELTACK:(i apphesilie)MiaMO_.;MO. M,.,``::......:
FROM TO MATERIAL r EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stomtwater Drainage ,
ft. ft.
❑Experimental Technology ❑Subsidence Control 20f<DR.LLItta .G:(attacti additioniiMii tsifiiecessary):; �.-. . E- .....,..,....;
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.soitfrock type.grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 67 ft. OVER BURDEN
08-19-2024 Well III# 67 ft• 305 ft• GRANITE
4.Date Well(s)Completed: ft. ft. '
5a.Well Location: ft. ft.
Alora Burrell
ft. ft.
Facility/Owner Name s Facility ID#(if applicable) •ft. ft. '
TBD Ponder Creek Rd., Mars Hill ft. ft. •
Physical Address,City,and Zip
2101E3VIARKS,; M,,M. -_ .....
Madison • 9779-67-0062 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 08-21-2024
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. Signature of edified Well Contracto 1 Date
6:is(are)the well(s): OPermanent or OTemporary By signing this firm.I hereby certitj•that the well(s)was(were)constructed in accordance
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• with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or l No •• copy of this record has been provided to the well owner. 7.
t�. ,
If this is a repair,fill out known well construction information and eaplum the nature of the Z r� •3 �*''.
repair under#21 remarks section or on the hack r f this form. 23.Site diagram or additional Well details: L.
,! `t' a... r
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 • You
details. You may also attach additional pages ifnec Es?y.1 6 2024
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: 305 (ft.) .24a. For All Wells: Submit this'form within 30 days of comprd#I°d c 'c C11
For multiple wells list all depths ifdiJferent(example-3(aj200'and 2(44100') 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 Servicei,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
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ROTARY 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: c• onstruction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resource s,;Underground Injection Control Program,
...4-- FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service,Center,Raleigh,NC 27699-1636
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4 • RIG 24c:For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 20 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural l(esources—Division of Water Resources Revised August 2013
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