GW1-2022-07768_Well Construction - GW1_20220822

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
_14..WATER ZONES
Kolby Mitchell Sawyers FROM .110 DESCRIPTION
Well Contractor Name ft. ft. I
4471-A ft. ft. I
NC Well Contractor Certification Number 15.OUTER CASING for multi-casedlwells)OR LINER(if a licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 66 ft- 16.25 in. #21 PVC
Company Namc 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:
2022-22610-9-11912 FROM THICKNESS MATERIAL
ft TO ft DIAMETER'tn
List all applicable well permits(i.e.Count),,State. Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM 1'0 DIAMETER SLOT SI7,E THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 It- 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Ston-nwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach addition a]lsheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) 0 ff 66 ft. OVER BURDEN
8-9_2022 66 ft 605 ft• GRANITE
4.Date Well(s)Completed: Well iD#
ft. ft.
5a.Well Location:
Michael D. Owenby
Facility/Owner Name Facility ID#(if applicable) f[. ft.
140 Weeping Cherry Drive Whittier, NC 28789 ft «•
Plrvsical Address,City,and Zip 21.REMARKS -
Jackson 7604-99-5900
Countv Parcel Itientification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification-.
(if well field,one lat/long is sufficient)
8-16-2022
N W
-I k , (.. r-
Ignature ofCertifi Well Contractor Dale
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,I herebl,cert/%v that the wIn,
v nwAs ct dance
With 15A NCAC t12C.0100 or 15A NCAC 02C.t1k-n •t�Yivra ha!a
7.Is this a repair to an existing well: ❑Yes or ElNo cop),gfthis record has been provided to the we/l o . e��-
Iftlhis is it repair,Jill ont known well construction in/brmation and explain the nature ofthe
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details: (II(� t: 2022
You may use the back of this page to provide addiGonarwAl site details or well
8.Number of wells constructed 1 construction details. You may also attach additionalpagestj€R , 0 Ua
For mmdtiple injection or non-water.supply wells ONLY with the same construction,you can l 1i 1BOG
submil one farm. SUBMITTAL INSTUCTIONS O•
9.Total well depth below land surface: 605 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
l'or multiple wells list all depths i1*dt(Ierent(exanpltte-3 200'and 2@100') construction to the following:
10.Static water level below top of casing: 80 (ft.) Division of Water Resources,Information Processing Unit,
Ilirater 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.) j
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I
13a.Yield(gpm) 3 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: 35 well construction to the county Health department of the county where
constructed. f
Form GW-I North Carolina Department of Environment and Nawral Resources-Division of WaterlResources Revised August 2013