GW1-2021-06224_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD E' For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Sawyers J :14.WATER ZONES
�, ,,yy?'� FROM TO DESCRIPTION
5
Well Contractor Name \\ �Ue,o�\ ft. ft.
4471-A P ��1�tsea
NC Well Contractor Certification Number
'J11 tv` 15 OUTER CASING for tuultrcased wells OR LINER if a i licable
CLYDE SAWYERS & SON WEK& PUMP INC +1�� rt• 66 r[ 25ETERIn THIC#215S MATERIAL VC
Company Name 16.`INNER CASING OR TUBING 'eothermal closed400
SAS-124W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: tt. t[. in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.) ft. ft, in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(sin(single) ft. ft. in.
1&.GROUT
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft.
Non-Water Supply Well: 20 ft. Bentoriite Pumped
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 1%SAND/GRAVEL PACK_if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
t[. it.
❑Experimental Technology ❑Subsidence Control
203DRII,LING LOG attach additional sheets if oecess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiltrock type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 t[ 66 f[ OVER BURDEN
07/05/2021 66 ft 165 t[ GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Derrick and Shannon Penland r[. ft.
Facility/Owner Name Facility ID#(if applicable)
r[. ft.
75 Elizabeth Chapel, Waynesville ft. ft.
Physical Address,City,and Zip
Haywood 8625-6-7-7420
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certific on:
(if well field,one[at/long is sufficient)
N W 07-06-2021
M.gnat.,e a if Well Contract Dale
6.Is(are)the wetl(s): RIPermanent or ❑Temporary By signing this form,I hereby certifv that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No 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 oflhe
repair under#21 remarks section or on the back of dtisform. 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.
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: 165 (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 1@100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 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:
(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 m 7 Method of test- RIG 24c.For Water Supply&Injection Wells:
(gp ) 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.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013