GW1-2021-06782_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Sawyers ,14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name It. ft.
4471-A ft. ft.
NC Well Contractor Certification Number 4,45.QUTER-CASING for mattress wells - LINER,if a licable >
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 52 rt• 6.25 #21 PVC
Company Name
16.INNER CASING OR TUBING `etithermal:elosed
WP21-026 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State, Variance,h jection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT S17E THICKNESS MATERIAL
ft. ft. in
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) E IResidential Water Supply(single) ft. ft. In
❑industrial/Commercial ❑Residential Water Supply(shared) 1S.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[]Irrigation 0 ft. 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 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 additiorialsheets if necess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sontrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 n' 52 rt' OVER BURDEN
06/21/2021 52 rt• 305 «• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. It.
P
Sherry Hunter
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
TBD Duncan Knob Rd. ft. fL
Physical Address,City,and Zip 21.REMARKS E
Transylvania 8552-43-7268-000(NEW) 3ttotl ;on
County Parcel Identification No.(PIN) o t
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certitic •on:
(if well field,one lat/long is sufficient)
06-21-2021 N N, IWAAAAL—wo-m-noe it
ignature oC e i tP
Well Contract Date
6.Is(are)the weB(S): ❑✓Permanent or ❑Temporary By signing this form,1 hereby cer•tifv that the we/l(s)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 END copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 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: 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: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.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.WeB 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
i
13a.Yield(gpm) 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: 30 well construction to the county health department of the county where
constructed. i
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013