GW1-2021-07293_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KalebT. Hyde e 14.WATER ZONES
Well Contractor Name �O 50 FROM
ft' 70 O ft DESCRIPTIONS
4436-A ' ".�� A. rt. rt.
NC Well Contractor Certification Number \\7 �irj��ej. 15.OUTER CASING for TELIAcased wells OR LINER if a licable
Graham Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
p ft. 55 ft- 6.25 in SDR21 PVC
Company Name 16.INNER CASING OR TUBING eother at closed-loop)
2.Well Construction Permit FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.111C,County,Slate, Variance,etc.) p ft. 4ftt,
in.
3.Well Use(check well use): ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in,
❑Geothermal(Heating/Cooling Supply) IlResidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri atlon ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 17 ft.
❑Monitoring ❑Recovery 17 ft. 20 ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiVrock e, min siu,etc.)
ft. ft.
4.Date Well(s)Completed: 07/20/2021 Well ID# ft. ft.
5a.Well Location: ft. ft.
Steve Cowperthw CLI A t ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Peacock Preserve, Whittier, NC 28789 ft. ft.
Physical Address,City,and Zip ft. ft.
Jackson 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification:
35 degrees 24' 54" N 83 degrees 20' 3" W K6 7/20/2021
6.Is(are)the well(s): CJPermanent or ❑Temporary Signature ofCertified W141Contractor Date
By.s•igning this Jornt,1 hereby certify that the me/l(s)was(mere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well omner.
repair under 921 rentarks section or on the back a/'thi.s fonn.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 705 (ft•) Submit this GW-1 within 30 days of well completion per the following:
For multiple melts list all depths ifdii fereni(example-3@200'and 2@I00')
50 24a. For All Wells: Original form to Division of Water Resources (DWR),
J Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/fmaer level is abm�e caring use"+"
11.Borehole diameter: 6.25 (in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rotary
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 12 Method of test: air
Pen-nit Program,1611 MSC,Raleigh,NC 27699-161 1
13b.Disinfection type: HTH Amount: 30 oZ
E
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Kolb Sawyers 14'WATERZONES
Y Y FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wgs OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 55 ft- 16.25 i" 1 #21 1 PVC
Company Name 16 INNER CASING OR TUBING(geothermal closed-loo
2020-19795-9-10334 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County.State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPIY(single) f. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.-GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrrigation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. R.
❑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 attactraddifional sheets if necessary)
❑Geothertal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiltrock type,grain sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 55 ft. OVER BURDEN
5-14-2021 55 ft• 125 ft- GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
Judith Williams ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1266 Macktown Road Sylva, NC 28779 ft. ft. ,
Plrvsical Address,City,and Zip 21.REMARKS '
Jackson 7621-73-1331pcn .;on
County Parcel Identification No.(PIN)
D
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field.one lat/long is sufficient)
N 5-19-2021
Signature ofCerto t d Well Con for Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(here)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 ID No copy ofthis record has been provided to the well owner.
ll'rhis is a repair.fill out known well construction information and explain the nature of the
repair under:21 remarks section or on the back o/'this jbrm. 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.
I•'ar multiple injection or non-water supply wells ONLY with the same construction,you can
submit one,/ortn 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
hbr nufluple wells/Is/all depths ijdl/ferent(example-3 a 200'and 2 ct 100') construction t0 the following:
10.Static water level below top of casing: 20 Division of Water Resources,Information Processing Unit,
lrwoter level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b. For Iniection Wells ONLY:j 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
(gP ) 24c.For Water Supply&Injection Wells:
13a.field m 30 Method of test: RIG
Also submit one copy of this forim 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 201