GW1-2022-05260_Well Construction - GW1_20220526

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 Connector Name
ft. I ft.
4471-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a, li able)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 52 tt• 6.25 i" #21 1 PVC
Company Name 16..INNER CASING OR-TUBING eothermal.closed-loo"
MCM-295W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List till applicable well permits(i.e.Count),,State. Variance,Ittiection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN '
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal Heating Cooling Supply) OResidential Water Supply ft. ft. in.
( � d PPY) PPY '
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 fc. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑AquiferRecharge ❑GroundwaterRemediation 1%SAND/GRAVEL RACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach'additional sheets if necessar
❑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. 52 ft. OVER BURDEN
4-12-2022 52 ft. 525 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
Sa.Well Location: ft. ft.
Ethan and Kayla Justice ft. st. 1—
Facility/Owner Name Facility ID#(if applicable) a
rt. ft. 6 n2!
Chinquapin Road Canton, NC 28716 ft. ft.
Physical Address,City,and Zip
21:..REMARKS s,
Haywood 8663-98-9162
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 4-26-2022
Signature of Certifi Well Contractor Date
6.Is(are)the well(s): OPermanent 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 ONo copy gfthis record has been provided to the well owner.
ll*ihis is a repair,fill out known well construction inforntalion and arplain the nature ofthe
repair under#21 rentarks 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 attach additional pages if necessary.
For multiple injection or non-water svtpply wells ONLY with the sane construction,you can
submit once form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 525 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(fdi(ferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing• 60 Division of Water Resources,Information Processing Unit,
If tearer level is above casing,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) 6 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 35 well construction to the county health department of the county where
constructed.
Fora G W-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013