GW1-2023-00605_Well Construction - GW1_20230105

WELL CONSTRUCTION RECORD For Internal Use ONLY: j
This form can be used for single or multiple wells i
1.Well Contractor Information:
Kolby Mitchell Sawyers FRO TO ESCRIFTION
Well Contractor Name ft. ft.
4471-A ft.
NC Well Contractor Certification Number
,S5;Ul11'�ERCASING Porrniti cased=webs .012t;INECt'fa'ltcstite'' ":�_
FROAf TO DIAMETER 1 THICKNESS AfATF.RiAi.
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 166 ft- 6.25 i #21 1 PVC
Company Name (] Wi NNER CASING Oft TU6111 C e0thetvial sieseti=lud'FW
2021-21728-9-11312 FROM ft 1'O ft• DIAMETER in 'THICKNESS MATERIAL
2.Well Construction Permit#:
List all applicable well pennies(i.e.County,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 1
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS NIATERi.4L
ft. ft. in.
❑Agricultural ❑Municipal/Public
in.
❑Geothermal(Heating/CoolingSupply) BResidential Water SuPP1Y(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 1ft GROi1T...�
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hTi ation 0 ec. 20 fr• Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation FROM
D1GRTELPAtK MATE eihl
RIAL EAIPLACEME.NT METHOD m
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
:.20 DRtCL1NG:IOG:attach additiiirt5lsheet§.ifiecessarv'�.. :...:. ..:.. ::...::
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiVrmk ri k grain size,etc.)
❑Geothermal (Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 66 ft. OVER BURDEN
1 0-24-2022 GRANITE
4.Date Weil(s)Completed: Well ID# 66 fc' 185 f<
ft. ft.
5a.Well Location: ft. ft.
LW LAND HOLDINGS LLC
Facility/Owner Name Facility ID#(if applicable) ft. ft. i I ~ 3
LT 8A LIGHT WATERS DRt. ft. y
Physical Address,City,and Zip 21 ►2EMARKS __. � E.{`;s.
Jackson 7568-08-6168
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) i
N WA r7
� 12/21/2022
Signature of Certify Yw
ell Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify tlmt the ti ell(s)was(were)constructed in accordance
with 15A NC.AC 02C..0100 or 1 SA NCAC 02C.0200 Well Construction Standardv and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy of this record has been provided to the well owner.
If this is a repair,fill out knouvu well construction information and explain the nature of the
repair under#21 remarlo•section or on the back oflhiv farm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details of well
8.Number of wells constructed: construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welly list all depths if different(example-3@200'and 2(a100) 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 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 withhi 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) 1`5 Method of test: RI G
24c.For Water Supply&Injectio I Wells:
Also submit one copy of this form within 30 days ofcompletionof
PILLS
13b.Disinfection type: Amount: 35 well construction to the county health department of the county where
constructed.
Forte GW-1 North Carolina Department of Environment and Natural Resources—Division of Wat Ir Resources Revised August 2013