GW1-2021-01581_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information: RECEIVE®
Kolb Sawyers FROM ER ZONES
Y y FROM TO DESCRIPTION
Well Contractor Name V ft. ft.
4471 A ♦ ft. ft.
'n1�rrC(t�t`/On PrQCeSSTfI�Unit <15.OUTER CASING for multi-cased wells OR++LINER ifa `licable
NC Well Contractor Certification Number DWR Sec.ion
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 r1' 72 et. 6.25 i" #21 1 PVC
Company Name 16.INNER CASING OR TUBING(geothermal l closed-loop).,
0191 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable we//permits(i.e.County,Stale,Variance,Injection,etc.)
ft. rt. 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) ElResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Trrigation 0 It' 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.rSAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
ssz -
❑Geothennal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sail/rock type,grain siu,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 72 fr. OVER BURDEN
1-05-2021 72 rr 165 ft GRANITE
4.Date Well(s)Completed: Well ID# fr. ft.
5a.Well Location: ft. ft.
Tom Harris ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
545 Dehart Cove Road Bryson City NC ft. ft.
Phvsical Address,City,and Zip 21.REMARKS ,
Swain
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one ladlong is sufficient)
N W 1-11-2021
Signature of Certifi ell Contracto Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofthis record has been provided to the well owner.
//'this is a repair,Jill out known well construction information and explain the nature of the
repair under'12/remarks section or on the back of this Jorm. 23.Site diagram or additional well details:
You may use the back 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.
Misr 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: 165 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hisr nwhiple srehs list all depths it chfferent(example-3@200'and 2@100') construction t0 the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
I/n ater level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection 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.auger,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.Yield(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 20l