GW1-2022-09438_Well Construction - GW1_20221017

I
WELL CONSTRUCTION RECORD For Internal Use ONLY:
i
This form can be used for single or multiple wells j
1.Well Contractor Information:
T4�tlTEli7A1�S" ....• ��zF... r>x 3.:>�k ,.. `�... . ... ...���:�:
Kolby Mitchell Sawyers FROM I TO DESCRIPTION
Well Contractor Name ft.
4471-A f` I
NC Well Contractor Certification Number 15 411TER•C1S[ls(t",.fonmrlH casedliielEs 01ti INRR If' llcable td
FROM TO DTAMF•TKR I THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 30 ft- 6.25 i" 1 #21 PVC
Company Name tb:.13VtYER C13VG OR'l UBINO epthet maE'clpsedlpt! = > %,'.:....:
FROM to DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:
2021-20783-9-10808 1t ft• in.
List all applicable well permits(i.e.County,State,Yariance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THTCKNESS MATERIAL
ft. fr. in.
❑Agricultural ❑Municipal/Publir
❑Geothermal(Heating/Cooling Supply) ©Residential Water Supply(single) ft ft
❑IndustriaUCommercial ❑Residential Water Supply(shared) FROM
TO MATERIAL EMPLACEMENT METHOD&AMOU-NT
❑bii ation 0 ft• 20 fr Bentonite Pumped
Non-Water Supply Well:
ft. fr.
❑Monitoring ❑Recovery
Injection Well: tt ft.
❑Aquifer Recharge ❑GroundwaterRemediafion I')PS 1NO VE
FROM I TO MATERIAL EDIPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Ex erimental Technology ❑Subsidence Control
P gY _2b:;#ftti>ut�N0:1'00-(attaelta7ditiurt�Ysheat�t�ecessa':. �` :.�...�..... .. �.,,�
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rmk ri t rain size,etc.)
❑Geothermal Heating/CoolingRetrun) ❑Other(explain under#21Remarks 0 ft' 30 ff• OVERBURDEN
8-11-2022 30 ft- 205 ft. GRANITE
4.Date Well(s)Completed: Well ID# ft it.
5a.Well Location:
Evans. Michael
Facility/Owner Name Facility ID#(if applicable) ft. ft.
#548 Forest Valley Rd ft. ft. lt;; „
Physical Address,City,and Zip Zt3REMA1tKb,", �;
L
Jackson 7673-21-7546
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 �
08/26/2022
V—r_Uk
Signature of Cettifi ell Coutractor Date
6.is(are)the well(s): 2Permanent or ❑Temporary By signing this f rm,1 herehv rerNfy that the well(.)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 M ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No copy of This record has been provided to'rhe well owner.
If this is a repair,fill out knmxn well construction information and mplein the nature of the
repair tender#2l remarks section or on the back ofthis jornt. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
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
SUBMITTAL INSTUCTIONS
submit one form.
9.Total well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iit different(crumple-3(d�00'and 2(a 100') Construction to the following:
10.Static water level below top of casing: 30 Division of Water Resources,Information Processing Unit,
(ft•)
If water level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection 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) 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: 35 well construction to the county Ireallh department of the county where
constructed. I
Fors GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
I
I