GW1-2022-02901_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This firm can be used for single or multiple wells ` �" ^"''� f r°'
I.Well Contractor Information:
DERRICK HEATH SAWYERS FROM ER ZONES �-
FROM 'I'O DESCRIPTION
Well Contractor Name
ft. ft. fTr v t" ui:+;W$1T fill
2436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased,,wells)OR LINER(if a Iieable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS AND SON WELL +1 ft. 105 ft- 6 5/8 in. #188 1 Steel
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
MCM-233W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. I in.
List all applicable well permits(i.e.Counq,,State. Variance,bjection,etc.)
ft. f[. 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
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single)
❑hidustrial/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: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANWGRAVEL PACK if a Iieable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑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,soil/rock e, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft, 105 ft. OVER BURDEN
12-17-2021 ft
ft.
4.Date Well(s)Completed: Well ID#
105 ft.
225 rr• GRANITE
5a.Well Location: ft. ft.
Stephen & Lisa Fish ft. ft.
Facility/Owner Nano Facility ID4(if applicable) ft. ft.
Meridia Gap Road Canton, NC 28716 f. ft.
Physical Address,City,and Zip 21.REMARKS
Haywood 8665-53-2566
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
Of well field.one W/long is sufficient)
N w S at A 12/29/2021
Signature o Cerufied Well Contra t
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 herehr ce Yj,thin the wetl(s)was(,vere)constructed in accordance
With 15A 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 EINo cops'gfthis record has been provided to the well owner.
If ihia is a repair,fill out known it ell consuvction information and explain the nature gfthe
repair tinder#2I remarks section or on the hack of this lore. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
A.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
Far multiple injection ar nun-water supply wells ONLY with the sane construction,con can
111htnil One form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For intt6iple wells list all depths ifdi(ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 50 Division of Water Resources,Information Processing Unit,
(ft.)
If stater level is above casing.use••+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6.25 (in.) 24b. For Injection Wells ONLY: In addition to sending the form to the address in
ROTARY AIR 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) 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: 20 well construction to the county health department of the county where
constructed.
Perm GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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