GW1-2021-00197_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
sI4:WATER ZONES' , = ',
Kolby Mitchell Sawyers FROM TO A DFSCRIPT ON
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-casidEVetts OR LINER if a''livable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 100 ft 5.25 in #188 Steel
Company Name 16 INNER CASING OR TUBING 6othermal closed-loo
SAS-174W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt. in.
List all applicable well permits(i.e.County,State. Variance,hyection,etc.)
ft. fL in.
3.Well Use(check well use): 7 SCREEN_ -..
Water Supply Well: FROM 'r0 DIAMETER sLOTSIZE I THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
ft.❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Uri ation 0 f� 20 ft Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG.-attach additional sheets if recess ?�
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness,soil/mck type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft 100 ft. OVER BURDEN
11-22-2021 100 ft- 185 ft. GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
Sa.Well Location:
Courtney Quick
Facility/Owner Name Facility ID#(if applicable) ft ft
128 Aby Lane ft. Z021
Physical Address,City,and Zip 2LREMARKS-->
Maggie Valley a� 7677-42-3608
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one]at/long is sufficient)
) Q, 11/23/2021
N W
Signature ofCerifi Well Contractor # Date
6.Is(are)the weil(s): OPermanent or ❑Temporary By signing this form,I hereby verb that the well(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 ElNo copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature q/due
repair under#21 remarks section or an 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: 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 oneform. pC SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi/ferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 30 (tt,) 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 Iniection 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) 10 Method of test:
RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this foim within 30 days of completion of
13b.Disinfection type. PILLS Amount: 35 well construction to the county health department of the county where
constructed. i
I
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013