GW1-2023-00608_Well Construction - GW1_20230105

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers FROM TO ATM s....... DESCRIPTION
Well Contractor Name ft. ft.
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4471-A ft. ft.
NC Well Contractor Certification Number 16.OuTr 2CASING foriitatdcascilsvetts'.Ott:LlN�ft-if'a` licatite ..h.:
FROM I DIAMETER TIHCKNF,SS I MATERiAi
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 47 ft. 6.25 #21 1 PVC
Company Name t6r:IlyNER C AS W0,0R'I't1RIN `eother uiaKchtsedrluti }
FROM DIAMETER THICKNFSS al
2.Well Construction Permit#:
2021-21733-9-11313 ft. ft, rn A'1'NRI.AI.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
in,
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/CoolingSupply) (Residential Water Supply(single) it. ft. in•
❑lndustrial/Commercial ❑Residential Water Supply(shared) 1ft•GROUT.... _..
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑h-ri ation 0 ft. 20 1 Bentonite Pumped
Non-Water Supply Well:
ft. tt.
❑Monitoring ❑Recovery
Injection Well:
A
❑Aquifer Recharge ❑Groundwater RemediationSIND(GRCELFAGif.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stotmwater Drainage
❑Experimental Technology ❑Subsidence Control
3Q DAILLiNGY UG'a[7aeL:adtlitiariaEsheefs d ireeessacv" ::
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type.grain size,etc.l
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) 0 ft. 7 ft. OVER BURDEN
4.Date Well(s)Completed: 10-21-2022Well ID# 47 ft 345 n GRANITE
rt. rt.
5a.Well Location:
LW LAND HOLDINGS LLC
Facility/Owner Name Facility ID#(ifapplicable) -
ft. ft. an.•o t.�. ...
LT 5B LIGHT WATERS DR ft. ft. JAN Q 5
Physical Address,City,and Zip :21 REMARIfS_E ,
Jackson 7568-08-9284 `
IiiiGr zrym..'1 rr:. r;
J`J:
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification..
(if well field,one laUlong is sufficient) '
N W L � 12/21/2022
Signature of Cc11ifi e l Contractor; Date
6.is(are)the well(s): PIPermanent or ❑Temporary By signing this form,1 herehv cergfy�'that the rvell(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 sA NCAC 02C.0200 Nell Construction Standards and that a
7.Is this a repair to an eidsting well: ❑Yes or ONn copy ofthis record has been provided to the well owner.
Ifthis is u repair,fill out known well cons"utiun information and explain the nature of the
repair under 921 remarla•section or on the back ofthis 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 w•non-water supply wells ONLY with the same construction,you can
submit onefor-m. SUBMITTAL INSTUCTIONS:'
9.Total well depth below land surface: 345 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@U100) construction to the following:
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
Ij'wnter level is above casing,use"+" 1617 Mail Service(Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection 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'
(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) 5 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this fotrn within 30 days ofcompletion of
13b.Disinfection type: Amount: 35 well construction to the county hei Ith department of the county where
constructed.
Form GW-1• North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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