GW1-2021-04681_Well Construction - GW1_20210517

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells s"
INJ
1.Well Contractor Information:
KolbSawyers 14.WATER ZONES
Y Y FROM TO DESCRIPTION
Well Contractor Name �Y, ft. ft.
4471-A ��� art U(Iit ft. ft.
>;s0s 0
NC Well Contractor Certification Number i` 3 ae, `4 iY ovl 15 OUTER CASING for multi cased wells ORLINER if a"licable
Q v 1;`3 FROM TO DIAMETER' THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 120 ft- 6.25 "" #21 PVC
Company Name 16ANNER CASING OR TUBING(geothermal.closed-loo
WP20-146 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well perinils(i.e.County,Stale, 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
ft. f. in.
❑Geothermal(Heating/Cooling Supply) ZlResidential Water SuPPIY(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.,GROiTT
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
❑Aquifer Test ❑Stormwater Drainage
ft, ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock e, rain sim,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 120 ft OVER BURDEN
3-12-2021 120 ft 345 ft GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft.
BENJAMIN GOLDEN ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
114 CONNESTEE ROAD BREVARD, NC 28712 ft. ft.
Plrvsical Address,Citv,and Zip 21.REMARKS -
TRANSYLVANIA 8584-30-6672-000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient)
N W �p ,�� 9 4-29-2021
Signature ofCe i ed Well Contr or Date -
6.Is(are)the w'ell(s): ©Permanent or ❑Temporary /3v signing this Zorn,I hereby certify that the hell(+)was(here)constructed in accordance
With 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standardv and that a
7.Is this a repair to an existing well: ❑Yes or [71No copy of this record has been provided to the ire/l owner.
if ihis is a repair.fill out knmrn hell construction information and explain the nature of the
repair under 21 renrarkv section or on the back o/'this Jorni. 23.Site diagram
or additional
well details:
You may use briti pa to
provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
l'or multiple injection or nun-u ater.supply u ells ONLY ivah the same construction,you can
submit one lortn. SUBMITTALINSTLICTiONS
9.Total well depth below land surface: 345 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
bhr ntrrhiple ire/Lc/i l all depths iJ dijierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:
60 (ft.) Division of Water Resources,Information Processing Unit,
It,titer/ere/is above cavigL,rive" 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
2 :
13a.Yield(gpm) 4 Method of test: RIG 4c.For Water Supply&Injection Wells
Also submit one copy of this form!within 30 days of completion of
13b.Disinfection type: PILLS Amount: 35 well construction to the county health department of the county where
constructed.
For GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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