GW1-2022-03009_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: -
14.WATER ZONES
Kolby Mitchell Sawyers FROM DESCRIPTION
Well Contractor Name ft. fit.
4471-A
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER J J _
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 76 ft- 6.25 I #21 1 PVC
Company Name 16.INNER CASING OR TUBING °eothermal closed-loop)
0460 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. I in.
List all applicable well permits(i.e.Counm,State. Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERAAI,
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling-Supply) ElResidential Water SuPPIY(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 rt. 20 ft- Bentonite Pumped
Non-Water Supply Well:
rt. R.
❑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 ft. fit.
❑Aquifer Test ❑Stonnwatcr Drainage
ft. ft.
❑Fxperimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Gcothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION(color,hardness,soiVrock type,gnin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 76 ft- OVER BURDEN
12-1-2021 76 fit• 185 fit• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: fit. it.
CMH HOMES fit. rt.
Facility/Owner Name Facility ID#(if applicable) ft. fit.
JACOBS ROAD LOT 12 BRYSON CITY LOT 12 28713
e. rt.
Phvsical Address,City.and Zip 21.REMARKS
SWAIN
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N w V7a 12-20-2021
Signature ofCenifi Well Conlractor' Date
6.Is(are)the well(s): ❑✓Permanent or ❑Temporary By signing this form,I hereby cerli(i;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 ONo cope ofthis record has been provided to the well owner.
11'this is a repair.fill out known well construction injnrmalion and etplain the nature ofthe
repair under#21 remorks section or on 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.
Far mtdtiple injection or non-water supph•wells ONLY with the sante construction,you can
cubmil one(orm. 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 till depths ifdi/ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:40 (fit) Division of Water Resources,Information Processing Unit,
if atzner 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) 7 Method of test: RIG 24c.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 countywhere
constructed.
Folm GW-I North Carolina Department of Environment and Natural Resources-Division of Water'Resources Revised August 201„