GW1-2023-00603_Well Construction - GW1_20230105

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers FROM TO A1lR•7Al!TES DESCRIPTIONT
Well Contractor Name
4471-A
NC Well Contractor Certification Number 15.:0UTEk-CAS[IVG:fociiulti caser1we11s:Of23INBft lf:a 'lieab[e>
FROM TO DIAMETER THICKNESS nrATF.RiAI.
CLYDE SAWYERS & SON WELL & PUMP INC +1 155 ft• 6.25 i" #21 PVC
Company Name 16,1NNEWCASIN0. RTliBINCY '4GtheraiaF ctpsed-lpq'
2.Well Construction Permit#:
2021-22571-9-11763 FROM R• TO DIAMP KIt to THICKNESS MATERIAL
List all applicable well pennits(i.e.County,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17:5CREEN:.:::: .......,.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. It. in.
❑Geothermal(Heating/CoolingSupply) gResidential Water SuPP1Y(single) fr ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM
< .�. . r•
AI TO MATERIAL EMPLACEMENT MF.TAOiI&AMOUNT
❑h•ri ation 0 et• 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
[]Aquifer Recharge ❑Groundwater Remediation 19;SANI37GRAEL-RAG❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT f11ETHUD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
20-D1uG ANG'UOG:attach'addltiunalsheets'idnecessarv'>.... ...
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sotUrmk type.grain size.etc.)
❑Geothermal (Heating/Cooling Return ❑Other(explain under Q1 Remarks) 0 ft 55 ft OVER BURDEN
10-25-2022 55 ft 205 ft GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location: ft. ft.
LW LAND HOLDINGS LLC ft• ft•
Facility/Owner Name Facility ID#(if applicable) ft. ft. J AN a
LT 10A LIGHT WATERS DR It, ft.
Physical Address,City,and Zip
Jackson 7568-08-4398
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 W 12/21/2022
Signature of Certifi e 1 Contractor Date
6.Ts(are)the well(s): RlPermanent or ❑Temporary By signing this form,I herehy certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and flint a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided to the well owner.
If this is a repair,fill out knona well construction information and explain the nature of the
repair under 921 remarlo•section or on the back of this farm. 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 nor-water supply wells ONLY with the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
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 rve(lr list all depths if dii fco'ent(aXample-3@200'and 2(a�100) construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
If muter 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 24aabove, 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.) j
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 Method of test: RIG
24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: Amount: 35 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Wa,r Resources Revised August 2013
4