GW1-2023-00607_Well Construction - GW1_20230105

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells {4
1.Well Contractor Information:
Kolby Mitchell Sawyers FROn`ATIrlilzoiv�s = `T `
FROM TO DESCRiPTTON
Well Contractor Name ft. ft. I ,
4471-A ft. ft. i
NC Well Contractor Certification Number t5;iOtJ1 ER'GASiNG for;matd.cased:wells.ORfLtN�ti'if:'a licatite
FROM TO DIAMETER TMCKNF.SS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 145 ft- 6.25 i in. 1 #21 PVC
C ienSoCNoCompany Name Q
2.Well Construction Permit#:2021-21732-9-11316 HHOaI ft. 10 ft. DIAMETER in THICKNESS MATERIAL.
List all applicable well permits(i.e.Coun y,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use):
.19. CItEEht.�..s.....
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft. it. in.
❑Indugtrial/Commercial ❑Residential Water Supply(shared) tt1:Gfk01)T. a.... .. .y
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑li,; ation 0 et• 20 ft. Bentonite Pumped
Non-Water Supply Well:
it. [L ,
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft fr.
❑Experimental Technology []Subsidence Control
20-1fTtIL[311�'G:LOG.attaeh atliitttoeCsheets>iftecessacv.'" s ...... : ....,.y......
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrmk type. rein size,etc.)
❑Geothermal (Heating/Cooling Retum ❑Other(explain under#21 Remarks) 0 ft. 45 ft. OVER BURDEN
10-24-2022 45 f/ 165 ft ! GRANITE
4.Date Wells)Completed: Well ID#
5a.Well Location: ft.
Ell
LW LAND HOLDINGS LLC ft. ft. --
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
LT 6 LIGHT WATERS DR
ft. ft. ,
Physical Address,City,and Zip
Jackson 7568-08-8273
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
N WAir M
' 12/21/2022
Signature of Certifi ell Contractor 1. Date
i
6.Ts(are)the well(s): OPermanent or ❑Temporary By signing this firm,1 hereht•certify'tliat the we/l(s)was(were)constructed in accordance
with ISA NCAC.02C.0100 or ISA NCAC 02C.0200!fell Consb•uction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain tire.nature of the
repair under#21 r•emar/a•section or on the back ofihis 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 if necessary.
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: 345 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(V00'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,
Ij'weter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I i
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY: iIn 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 Servick6nter,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method of test• RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this forth within 30 days of completion of
13b.Disinfection type: Amount: 35 well construction to the county iei Ith department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013