GW1-2022-05288_Well Construction - GW1_20220526

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers FR:WATERZOiVES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
NC Well Contractor Certification Number AS OUTER CASING'formulti-cased wells OR LINER if`a' `licable'
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 fc. 51 16.25 i" #21 1 PVC
Company Name 16.INNER CASING OR TUBING `eothermal closed400
TO DIAMETER THICKNESS MATERIALFROh[
2.Well Construction Permit#: 2021—2031 9-9-1 0597 fL ft in
List all applicable well permits(i.e.County,State,Variance•h jection,etc)
ft. ft. in.
3.Well Use(check well use): 17:SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
[]Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) E7Residential Water Supply(single) ft. ft. in.
�18.-GROUT,
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
it. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
El Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAYELPACK if applicable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
El Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20:'DRILLING LOG:attach additiooa[•sheets if necess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,grain size etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rt. 51 rt. OVER BURDEN
05-11-2022 51 ft 505 ft GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Broom, Walker M ft. it. I
Facility/Owner Name Facility ION(if applicable)
ft. ft. MAY
Lot D2 on Oak Ridge Rd.
Physical Address,City,and Zip + r3
�41°'-REMARKS'`. . - t•°,�� e�l�;
Jackson 7598-10-3345
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)
N `,1, 05-11-2022
Signature of CertifilyWell Contractor Date
6.Is(are)the well(s): 171'ermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or KNo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back ofdrisform. 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 or non-water supph•wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 505 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+•• 1617 Mall 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
13a.Yield m 2 Method of test: RIG 24c.For Water Supply&Injection Wells:
(gp ) 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.
Foray GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013