GW1--05631_Well Construction - GW1_20240916

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1,
WELL CONSTRUCTION RECORD For Internal Use ONLY: I'
This form can be used for single or multiple wells
1.Well Contractor Information: • I'
Derrick Heath Sawyers • SI4RWAlkiUt . w — 4«a
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2436-A ft. ft. I I
NC Well Contractor Certification Number
152FOtt t tlir AStNG.(ftWJii lti cateithio).ORLIPIER(if uppticabtee)` fsi`wsl;`:,:/
FROM TO DIAMETER ' THICKNESS AfATF.RIAi.
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft' 85 ft• 6.25 in. #21 Pvc
Company Name id1NtVER`CASti\',Cw,OR:T.UBiNG(t ea`fJteriifaGclosed-looP) � w
EH25588 FROM DIAMETER THICKNESS MIATERIAl.
2.Well Construction Permit#: ft. ft. I, in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. ., in. -
3.Well Use(check well use): 'W1,1,.56>1tEENA; , ,i .W4.0 --KM.ar K-Wg'<r _ P./. , s'x
Water Supply Well: FROM TO . DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑MunicipaUPublic •
❑Geothermal(Heating/Cooling-Supply)) elResidential Water Supply ft. ft. in.
(H Coolin Su I g/ g pp y pp y(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) ;tS GitOU t..., t :w n �' x' Utz..
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft. 20 ft, Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft. Cap Top with Bentonite Chips
Injection Well: • ft. ft. ,
❑Aquifer Recharge ❑Groundwater Remediation9.1SA1!IEi/GRAVEL.PACK`(il.apjiliciiiSe)t ,. '4V0. ? v �``�``�
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage -
ft. ft.
❑Experimental Technology ❑Subsidence Control
111}11t1C[:I1 G (?.G.(attael latilhandl sftWif fiecessa ti 1; s sF "
❑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 fa 85 ft. OVER BURDEN '
9-4-2024 85 rt• 265 rt• GRANITE
4.Date Well(s)Completed: Wel11D#
ft. ft.
Sa.Well Location: ft. ft. .
LAWSON HAMILTON ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
179 LOKA HILLS ROAD COLUMBUS, NC 28722
I. ft. .
Physical Address,City,and Zip ; . z . =-rt°
POLK P48-307 Z�.x�E�rAR��� � .��,������ w . �� ���� .
Wet\ Oa Self 'C',ec-V ,eck
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) I.
N • w IA S ,V I :I. .;.!,'. :!
9-9-20 4 _
Signature of citified Well Contract / �T`IC t.p�„e
6.is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the wellO)was(were)constru t 1" a�{,eeoi'tiant�tt� AA
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction SI i/kdc4sut%haLP CT
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided to the well mower.
If this is a repair,fill out known well construction information and explain the nature of the 23.Site diagram or additional well details: OE��;;;..'c` rt_n el5ti•':y t
' repair under fill remarks section or on the back of this fbrm. h1 c;r..; r ��
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You may use the back of this page to provide additional well site d�i`ils't3t=A1'll
S.Number of wells constructed: construction details. You may also'attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-9 a 00'and 20)100') construction to the following:
10.Static water level below top of casing: 70 (ft.) Division of Water Resources,Information Processing Unit,
If water 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.e.auger,rotary,cable,direct push,etc.) f
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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8 RIG 24c.For Water Supply&Injection(Wells:
13a.Yield(gpm) Method of test: I
Also submit one copy of this fral e within 30 days of completion of
PILLS
13b.Disinfection type Amount: 25 well construction to the county health department of the county where
constructed. !
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Form OW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013