GW1-2022-02920_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD For Internal Use ONLY: f
This fin-in can be used for single or multiple wells E
ZAVED
1.Well Contractor Information: 14.Kolby Mitchell Sawyers FROM ER ZONES
FROM "I'O DESCRIPTION
Well Contractor Name ft. ft. It'lfi2kT•n`1ti,iai i,fOr;:n3�:!n0 Unit
4471-A fL ft. 1 010013
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a FROM TO DIAMETER Gcable THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 100 16.25 i #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:
2021-20364-9-10642 tt ft in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
ft.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM 110 DIAMETER SLOT SIZE THICKNESS MATF.RIAI.
ft. ft. in.�
❑Aericultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrieation 0 rt. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquitcr Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquitcr Test ❑Stonnnwater Drainage
ft. ft.
❑Gxperimcntal Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gnin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fit' 100 ft OVER BURDEN
11-30-2021 1010 ft 365 tt GRANITE
4.Date Well(s)Completed: Well rD#
tt. rt.
5a.Well Location: ft. ft.
Benjamin Alfred Powell ft. ft.
Facility/Owner Nano Facility ID#(ifapplicable)
176 Hensley Cemetary Road Whittier, NC 28789
Physical Address,City,and Zip 21.REMARKS
,Jackson 7612-48-0650
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(it\well field.one fat/long is sufficient)
12-20-2021
N W
Signature of Certify Well Contractor I Date
6.Is(are)the well(s): OPermanent or ❑Temporary Br 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 ENO cony ofthis record has been provided to the well owner.
I/'this is it,epair,/ill oul known well construction information and explain the nalure of the
repair under ii2l remarks section or on the back o/'thisJorm. 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: 1 construction details. You may also attach additional pages if necessary.
For nndtiple injection or non-water supply wells ONLY with the same construction,you can
suhnia one for'trr SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 365 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi/ferent(&ample-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
U rrale,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
13a.Yield( p )o m 5 Method of test: RIG 24c.For Water Supply&Injection Wells:
b
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 35 well construction to the county health department of the county where
constructed.
Fortn GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013