GW1-2022-10177_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor information:
Kolby Mitchell Sawyers 1R.WATERZONES ;
FROM TO DESCRIPTION
Well Contractor Name
4471-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a"lieable
FROM TO DIAMETER' THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 115 ft• 6.25 i #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
MCM-368W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt. in.
List till applicable well permits(i.e.County,State. Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft.❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ft. tt. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
CD Irrigation 0 ft. 115 ft• 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 Test ❑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,soil/rock type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft• 115 ft. OVER BURDEN
10-18-2022 115 ft• 425 ft• GRANITE
4.Date Well(s)Completed: Well 1D#
rt. rt.
5a.Well Location:
Danny Logan
Facility/Owner Name Facility iD#(ifapplicable)
103 Logan's Leap Canton, NC 28716 ft. Nov
Physical Address,City,and Zip "21.REMARKS '
Haywood 8666-24-2856 lo°
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
I if well field,one]at/long is sufficient)
N 10-24-2022
Signature ofCe;Dii Well Contractor Date
6.Is(are)the well(s): R Permanent or ❑Temporary By signing this form,1 herebv cerfift that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC,02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E!lNo copy of this record has been provided to the well owner.
10his i.c a repair,fill out known well construction information and explain the nature of the
repa;r under#2/remarks section or on the back of this,%rn. 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 ifnecessary.
ror multiple injection or non-water supph•wells ONLY with the sane construction,you can
suhuit m(-loon. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface•425 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
ror multiple wells list all depths ifdgjerent(example-3 a)200'and 2@100') construction to the following:
10.Static water level below top of casing: 60 ({t) Division of Water Resources,Information Processing Unit,
//hater 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) 2 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
Foray GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013