GW1-2022-09433_Well Construction - GW1_20221017

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
Kolby Mitchell Sawyers 14.WATER ZUNE5
FROM 'CO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
NC Weil Contractor Certification Number 15.:OUTERCASING(for multi-cased wells)OR LINER(if a licable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 115 ft- 6.25 : in. #21 1 PVC
Company Name 16.INNER CASING OR TUBING "'ottiermal closed-loop),
E H-21416 FROM TO DIAMETER' THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft.
List all applicable well permits(i.e.Count)',State,Variance,byectiart 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) ElResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
CA-lttifer Storage and Recovery ❑Salinity Barrier FROM ft. TO rt. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage
ft. rt.
❑Experimental Technology ❑Subsidence Control
30.DRILLING LOG(attach additional sheets if riecessar ,".,-•• °".
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 115 ft. OVER BURDEN
8-30-2022 115 ft- 165 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Robert McGuinn
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Turning Leaf Lane Lot 7 Mill Spring, NC 28756
rc. rt.
Physical Address,City,and Zip tD''' f>i "-� I ;I
Y Y P
Polk P65-57 21:REMARKS
County Parcel Identification No,(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification
(if well field,one tat/long is sufficient) i
N 09/14/2022
Signature orCertifi Well Contractor Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary B,signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 15.4 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 KNo copy gfthis record has been provided 10 the well owner.
1l this is a re pair,fill out known well construction information and explain the nature of 1he
repair under#21 remarks section a-on the back ol'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: I construction details. You may also attach additional pages if necessary.
For multiple injection or non-water suppPo wells ONLY with the same construction.You can _
submit one,farm. 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 nudtiple irells list all depths ffdfflerent(example-3@200'aid 2@I00') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing.Unit,
1f irater level is above casing,use"+" 1617 Mail Service Certtter,Raleigh,NC 27699-1617
i
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 thisi 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) 20 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: 2O well construction to the county hea!Ith`department of the county where
constructed. +I
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013