GW1-2021-00222_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:
Kolby Mitchell Sawyers F4.WATER ZONES
F'ROM 'ro_____L DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-caseilwells)OR LINER if a' ticable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 It. 110 ft- 6.25 in 421 1 PVC
Company Name 16.INNER CASING'OR TUBING(geothermal closed-loop)
FROM TO I DIAMETER I THICKNESS
2.well Construction Permit#: 201 9-1 3608-9-1 1 1 1 0 ft• ft 4'n
MATERIAL
List till applicable wellpermits(i.e.County,.State. Variance,Injection,etc.)
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
f[. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) El Residential Water SuPP1Y(single) ft. fr. in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑li-rigation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquiter Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonmwatcr Drainage
ft. ft.
OExperimcntal Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft, 110 ft. OVER BURDEN
10-17-2021 110 ft. 505 ft. GRANIT
4.Date Well(s)Completed: Well ID#
rt. rt.
5a.Well Location:
Ivan Hill ft. R.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
168 Willow Meadow Circle Sylva, NC 28779 ft. rt.
Physical Address,City,and Zip 21.REMARKS
Jackson 7662-54-5831
County 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)
Yl'r " )N w
11-8-2021
Signalure olCerfifilyWell Contractor F Date
6.Is(are)the well(s): ❑✓Permanent or ❑Temporary By signing this form,I hereby certyJ that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NC,4C 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the well owner.
If this is a repair.jilt out known well ron.struct:an information and e.rplain the nature of the
repair under#21 remnr/s section or on the hack 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.
Fur multiple injection or non-water.supplr wells ONLY with the sane construction,mu can
sethmit one farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 505 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths if'd/fjerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 80 (ft,) Division of Water Resources,Information Processing Unit,
If it level is above casing,rise*•+" 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.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m 3 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: 35 well construction to the county health department of the county where
constructed. I
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013