GW1-2021-01525_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD F For Internal Use ONLY:
This form can be used for single or multiple wells S E l
I.Well Contractor Information: RE v
Kolby Sawyers mot, S no�� 14.WATER ZONES
A A 1\ik L FROM TO I DESCRIPTION
Well Contractor Name ft. ft.
4471 A J�forM4 r Pr° ssin9 Ulit
ft. ft.
tint►
NC Well Contractor Certification Number WR`�� 15.OUTER CASING.:tot•multi-cased wells OR LINER if a "livable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC }1 ft• 42 ft- 6.25 #21 1 PVC
Company Name 16.INNER CASING OR`TUBING eothermal closed-loop)
NRH-217W FROM TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in•
Li.vi all applicable hell permits(i.e.County,State,Variance,Injection,etc)
ft. ft. in.
3.Well:Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(sin(single) ft. f. in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD!—AMOUNT
[Irrigation 0 tt' 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a livable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION tutor,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 42 ft. OVER BURDEN
1-4-2021 42 ft- 165 1" GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
APPALACIAN MTN INVESTMENT ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
SALLYS BRANCH ROAD CLYDE NC 28721 ft. ft.
Phvsical Address,City,and Zip 21,REMARKS
HAYWOOD 8733-48-7433
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if'well field,one]at/long is sufficient)
N W Q �O� 1-12-2021
Signature of'Cer&d WeITContractoU Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with I5A NCAC 02C.0I00 or I5A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No copy ofthis record has been provided to the well owner.
I/'this is a repair,Jill out known well construction information and explain the nature of the
repair under"2/rentarkv.section or on the back of thi.y Jornt. 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: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water.supply welly ONLY with the same construction,you can
submil one.1brm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 165 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Por nwhiple welly list a//depths tf'difJerent(example-3 a@i 200'and 2 100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
Ifltater level is above casing,use"+.. 1617 Mail Service Center,Raleigh,NC 27699-1617
1.Borehole diameter: 6.25 (in.) 24b. For Infection Wells ONLY: In 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.anger,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.field(gpm) 15 Method of test: RIG
24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 20 well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013