GW1-2022-02921_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Kolby Mitchell Sawyers FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
NC Well Contractor Certification Number t5.OUTER CASING formulti cased welts OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 196 ft. 6.25 1n #21 1 PVC
Company Name 16.1NNER'CASINGORTUBING eothermalelosed-loo
TO DIAMETER THICKNESS MATERIAL
FRont
2.Well Construction Permit#: 2021-2201 1-9-1 1 492 ft ft in.
List all applicable well permits(i.e.County,State. Variance,h jection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.xSCREEN
Water Supply Well: FROM 1'0 DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 rt. 20 ft- Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrierft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology El Subsidence Control
20.DRILLING LOG attach additions[sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,son1mck type,grain size,etc.
❑Geothermal(Heating/Cooling Return) []Other(explain under#21 Remarks) 0 ft. 96 ft. OVER BURDEN
2-15-2022 96 ft 165 ft GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
CMH Homes INC ft: ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
46 Happy Valley Rd
Physical Address,City,and Zip 21.-REMARKS
Jackson 7631-10-5950 -
County Parcel Identification No.(PIN) 02�
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification•
(if well field,one lat/long is sufficient)
N W
Signature of Cci fi Well Contractor t'1- i• Dale
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this form,1 hereby cert jv 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 ONo copy of this record has been provided to'the well owner.
lfthis is a repair,fill out known well construction information and explain the nature gfihe
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
8.Number of wells constructed: construction details. You may also,anach additional pages if necessary.
For multiple injection or non-water supphv wells ONLY with the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 165 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi(ferent(example-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,
lfwater 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
13a.Yield m 30 Method of test: RIG 24c.For Water Supply&Injection Wells:
(gp ) Also submit one copy of this form within 30 days of completion of
136.Disinfection type: PILLS Amount: 35 well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013