GW1-2022-02922_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
Weli Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING((or multi-eased.wells)OR LINER if a ticable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 69 ft• 6.25 #21 1 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed400
TO DIAMETER THICKNESS MATERIAL
FRonf
2.Well Construction Permit#: 2021-21 696-9-1 1 371 ft ft in.
List all applicable eel/permits(i.e.County,State. Variance,Injection,etc.)
n. ft. in.
3.Well Use(check well use): 17.SCREEN i i
Water Supply Well: FRoml TO DIAMETER SLOT SIZE THICKNESS MATERAAIl
ft. ft. in.
❑Agricultural ❑lvlunicipal/Public
❑Geothermal(Heating/Cooling Supply) EIResidential Water SuPP1Y(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 tt. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Tcst ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,gnin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft. 69 ft. OVER BURDEN
2-15-2022 69 ft 165 ft GRANITE
4.Date Well(s)Completed: Well fD#
5a.Well Location:
ERNIE AKINS
Facility/Owner Name Facility ID#(if applicable) ft. ft.
660 SOLS CREEK CHURCH ROAD TUCKASEGEE, NC 28783
ft. ft. I F p
Physical Address,City,and Zip 21.REMARKSwinm
s
JACKSON 7597-72-6311 %* Uw
County Parcel Identification No.(PIN) hap�
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
61'well field.one]at/long is sufficient)
02/16/2022
N W
Signature ofCcrtifityWell Contractor f Date
6.Is(are)the well(s): ❑✓Permanent or ❑Temporary By 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 EINo copy gfthis record has been provided to the wel/owner.
ll this is a repair,.jill out known well construction information and erplain the nature oflhe
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: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-naler supply wells ONLY with the same construction,You can
submit nnc form. 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 ij d#krent(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,
If water level is above caring,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) 7 Method of test: RIG
24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 20 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
i