GW1--06665_Well Construction - GW1_20241108

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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:
Derrick Heath Sawyers :AlamArErtIoNtsi,xa r ; m ; ;dr„ k 4 K,-.-,
FRONT TO DESCRIPTION
Well Contractor Name ft. ft. I i
2436-A . ft. ft. i
.
NCR'ellContractorCeilificationNumber 15 OU.TCR•GASINalivi:'tuiilivaiii s�ielts}ARttNEft(if " ii abizymt ,. ' r.
FROM • TO DIAMETER• THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 78 fit• 6.25 .l"• #21 PVC ,
Company Name 516 riNNER2?Oi1SttYU'ORTt7131NG'(ieitheivtnt cl6sed'ipop o-�'.',��w: re
MCM-785 FROM 'r0 DIAMETER THICKNESS !MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,Slaw,Variance,Injection,etc.) ft. It. in.
3.Well Use(check well use):
tf7.,SGRE>;N:MI z S.T4f •kM: liMat rw*ski;., .. :«'_?
Water Supply Well: FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL t
❑Agricultural , ❑Municipal/Public ft. ft. in.
ID Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft. in..
1$:°GiOiaT `M":Li: r,;?d "zr ,E�w a .p ,. :.s:. `f# r,-it ,ak `,
❑IndustriaUCommercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Tnigation 0 fit. ft
Non-Water Supply Well: 20 Bentonite Pumped
❑Monitoring DRecovery ft. ft. Cap Top with Bentonite Chips
injection Well: ft. ft.
❑Aquifer Recharge 0 Groundwater Remediation 5194SAND/GRAVEIw:YA'GK(1-ap ii eiitil`e)MEMV MWaIa Z 1
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft. j.
❑Aquifer Test ❑Stormwater Drainage -
ft. ft
❑Experimental Technology • ❑Subsidence Control
z.20DRittING,LOG,(attach iddihonal"s"sheets if aecessary) h` ' ^. c
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color;hardness,soiUrock type.grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fit• 78 ft. I ; OVER_.RURDEN
4.Date10-29-2024 78 fir• 205 fit• GRANITE;, ' i
Well(s)Completed: Well ID# ft. ft. 0 8
Sa.Well Location: ft. ft. NOV 2024
JONATHAN&BRITTANY WORLEY • ft. ft. ' r_•,...;:^
Facility/Owner Name Facility ID#(if applicable) ft. ft. ir'r ai,t;!i_„: -
111 SUNNY ACRES DRIVE CANTON, NC 28716 rt. fit.
Physical Address,City,and Zip �M. V ,,T `�-
e2U.�REiNARKS"+�� ziv�,r� "?uY� r. sf,..3E``a..x... ,<
HAYWOOD WELL WAS SELF CERTIFIED
County Parcel Identification No.(PIN) I i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: '
(if well field,one lat/long is sufficient)
N W 11-1-2024
. SignaturJ4k citified Well Coutract j Date
6.Ts(are)the well(s): CdPerntanent or ❑Temporary Y signing f (�
B si nnin•this form,I herehv certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided to the well owner. •
fit/us is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the hack of this jam. 23.Site diagram or additional well details:
• You may use the hack of this page,to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply sells ONLY with the same construction,you can i'
submit one form. 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 wells list all depths if di/Jerent(example-3(4 00'and 26t100') construction to the following: • :
.to.Static water level below top of casing: 50 (ft.) Division of Water Resources,Information Processing Unit,
Il'snter level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25
(in.) 24b.For Injection Wells ONLY:I In addition to sending the form to the address in •
ROTARY 24a above, also submit a copy oft: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.) i
Division of Water Resources,Underground Injection Control Program,
• FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 6 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount 20 well construction to the county health department of the county where
constructed.
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Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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