GW1-2021-01552_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD For Internal Use ONLN':
This lin'ns can he used for single or multiple wells `I
I.Well Contractor Information: RECEIVED
KolbSawyers 14.WATER ZONES
y y FROM TO DESCRIPTION
%X'ell Contractor Nante y ft. ft.
ft.
4471-A I9crmation Processing Unit ft.
N(" WellContractuw'CertificationNumber D\NRSection 15.OUTER CASING(for multi-casedwells OR LINER ifa lieable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 147 ft• 16.25 #21 1 PVC
Company Name 16.INNER CASING OR TUBING eothertnal closed-loop)
2019-13854-9-10573 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: fr. ft. in.
l.u.st oll aly,licahle,cell permits(i.e.t btttpt Stole.Kmance,hrjectio•c etc.)
ft. ft. in.
3.Well I.Ise(check well use): 17.SCREEN
Water Supply Well: FROM I TO I DIAMETER SLOT-SIZE I THICKNESS I MATERIAL
ft. ft. in.
❑A_i icultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) EIResidential Water SuPPIY(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrrigation 0 fry 20 ft- Bentonite Pumped
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge 0Gr0tlndwater Remediation 19.SAND/GRAVEL PACK ifapplicable)
FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. fry
❑Aquifer Test ❑Stormwater Drainage
ft. I ft.
❑Fxperimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION(color,hardness,soil/rock typt,grain sim,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 47 ft. OVER BURDEN
2-3-2021 47 ft 125 ft. GRANITE
4.Date Well(s)Completed: Well ID#_ ft. ft.
5a.Well Location: ft. ft.
Bethany J Grogan ft. ft.
FacilimOwneiName Facility Ill#(ifapplicable) ft. ft.
520 Dark Ridge Road Sylva, NC 28779 ft. ft.
Physical Address.City.and Zip 21.REMARKS
Jackson 7672-26-0952
Counly Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if\cell field.one lit/long is sufficient)
N W 2-15-2021
Signal a ot'Cert' d Well Contr ct r Date
6.Is(are)the w'ell(s): 9 Permanent or ❑Temporarl By signing this brit.I herehv cert/Jv that the well(s)was(were)constructed in accordance
Y with 15A NCB( 02C.0100 or 15A NCAC 02C.0200 Well Consirucrion Standards and that a
7.Is this a repair to an existing well: ❑Yes or (KINDcopyol'dris record has been provided/to the well owner.
/duo Ls a repair.Jill out known well construction inlorinution and explain the nature ql the
r"Iwo-under ,l remurkr.certion ur nn the hack q/'rhitJbnn. 23.Site diagram or additional well details:
You may use the back of this page to pffvide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
l,or»adtple Inert ion or non-,rater suppi v wells ONLY,riih the same construction.you can
,ubn»t oar 1hrm. SUBMITTAL INSTUCTIONS
9."Total well depth below land surface: 125 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
lbr»ndtip/e we//s list all depth.,i1 d/11&rett(example-3 a.200'and 2 a/00') construction to the following:
10.Static water level below top of casing: 20 Division of Water Resources,information Processing Unit,
(1van•r lore/is uhmr euetrt,ace" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.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:
li.e auger,rotary,cable,direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR••'%'ATF,R SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I3a.field(gpm) 40 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.
Fom,GAW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013