GW1-2023-00606_Well Construction - GW1_20230105

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers FRO-TO DESCRIPTIONi . .3 :::,,.
Well Contractor Name ft. ft. I
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4471-A ft. ft.
NC Well Contractor Certification Number 15,OUT1;It:CAStmq for"muHrcasel veils'OIfL1N�R:if'a''licatiie'
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 66 ft- 6.25 i" #21 1 PVC
Company Name 165 N N E 9"RAS IN0.OR''fUfmo' "'theratai'clo5ed 140"
2.Well Construction Permit#: 2021-21 731-9-1 1 31 7 ERont ro ft ft. DIAMN 1'KR in THICKNESS alA'I'N R141.
List all applicable well permits(i.e.County,State,Yar•iance,Injection,etc.) ft ft. in
3.Well Use(check well use): a?.`5G1tEhl!l.:.E.
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THfCKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft. it. in.
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft. ft. in.
❑Indwarial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&ANTOUNT
❑Trri ation 0 ft' 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. tt.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19;�SSiVI3/GRALPAGR )i a" "able t ._._. .x.
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stomiwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20sDRI1 tNCLOG atta_eh.addlho alsheiit§R,iiecessa"rv';:... .
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardness,sotvrmk type. rain size.etc.)
❑Geothermal (Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 66 ft• OVER BURDEN
10-24-2022 4.Date Well(s)Completed: Well ID# 66 ft- 185 ft. GRANITE
ft. ft.
5a.Well Location: it. ft. •xv
LW LAND HOLDINGS LLC "
�C mac,
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. ti /O23
LT 7 LIGHT WATERS DR ft. ft. Lv
Physical Address,City,and Zip
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21:;BEMARIfS;.
Jackson 7568-08-7261 Jai �ti�r�ri
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 C. 12/21/2022
Signature ofCertifi a Contractor, Date
6.is(are)the well(s): ©Permanent or ❑Temporary By signing this form,1 hereby verify that the well(s)ivus(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 H'ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy ofthis record has been provided to the well owvre:
]fthis is a repair,fill uut knomi well construction information and explain the nature of the
repair under#21 remarks section or on the back ofthis form. 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 ifnecessary.
For multiple injection or non-water supply wells ONLY with the sanie 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 wells list all depths iftlijfcrent(erample-3 ut 00'and 2(a,1001 construction to the following: i.
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 0nter,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY: 4n addition to sending the form to the address in
ROTARY 24a above, also submit a copy of this fort 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 ServicelCenter,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method of test: RIG
24c.For Water Supply&Injection Wells:
Also submit one copy of this fortis within 30 days of completion of
13b.Disinfection type. PILLS Amount: 35 well construction to the county het lth department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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