GW1-2021-00200_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
14.WATER ZONES
Kolby Mitchell Sawyers FROM DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased,'wells)OR LINER(if a able)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 162 ft 6.25 ' in. #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
SAS-177W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft• ft. in.
Lin 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
ft. ft. in•',
❑Agricultural ❑Municipal/Public
❑Geothenmal(Heating/Cooling Supply) ElResidential Water SuPPIY(single) f. ft. in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
tt. rc.
❑Ihlon itoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
ft, ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc.
[]Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 tt. 62 rt. OVER BURDEN
10-22-2021 62 ft 465 ft GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
HOMER DOUGLAS ft, ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
424 ARRINGTON ACRES WAYNESVILLE, NC 28786
Phvsical Address,City,and Zip 21.REMARKS
HAYWOOD 7694-86-4663
Countv Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
11/10-2021
N W
Signature of Certifi Well Contractor Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this orm v,I hereby cerh that the well(s)was were constructed in accordance
With 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©NO cope ofthis record has been provided to the well owner.
11 rhis is a repair.fill nut known well construction information and explain the naarre ofthe
repair under'21 remarks section or on the back at 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 muhiple inje(ifi,n or non-water supply welly ONLY with the saute construction you cart
SUBMITTAL INSTUCTIONS
suhntil One Jorrn.
9.Total well depth below land surface: 465 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i/'different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
1/tarter 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(gpm) 20 Method of test: RIG 24c.For Water Supply&Injection Wells-
Also submit one copy of this form within 30 days of completion of
13h.Disinfection type: PILLS Amount: 20 well construction to the county health department of the county where
constructed.
Forth GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013