GW1-2021-00265_Well Construction - GW1_20211213

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 DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a l cable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft 24 ff• 6.25 in. 1 #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
WP21-102 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt. in.
1_i.rt all applicable well permits(i.e.County.Smte, Variance.Injection,etc.) R. CL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER( SLOTSIZE THICKNESS MATERIAL
ft. ft. in:
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) EDResidential Water SuPPIY(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:
rt. rc.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
❑Geothenmal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)J 0 ft. 24 ft. OVER BURDEN
10-25-2021 24 f'• 765 ft. GRANITE
4.Date Well(s)Completed: Well ID#
rc. rt.
5a.Well Location:
WILLIAM & ELLEN NESBITT rt. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. •EI.
LAKE TOX ESTATES LOT 39R LAKE TOXAWAY NC 28747
Physical Address,City,and Zip 21.REMARKS
TRANSYLVANIA 8513-13-9534-000
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)
N W 11-2-2021
Signature of Certify Well Contractor Date
6.Is(are)the well(s): (]Permanent or ❑Temporary By signing this form,l herebv certiiti that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NC IC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or IDNo cope gjthis record has been provided to the well owner.
ll'dri.s is a repair.fill ual known well construction injimntraion and explain the nature of the
repair under#21 rewards section or on the back of this./orm. 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: 1 construction details. You may also attach additional pages if necessary.
For mmltiple injection or nun-water supply wells ONLY with the saute construction,you can
suhmit One/nrne cG SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 765 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ll'di/jerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:
100 Division of Water Resources,Information Processing Unit,
(ft.)
If water level is above easing.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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
20 RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: i
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.
Font GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013