GW1-2022-05289_Well Construction - GW1_20220526

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.Kolby Mitchell Sawyers FROM WATER ZTO ONES - DESCRIPTION
Well Contractor Name ft. ft.
4471-A
NC Well Contractor Certification Number
d5i OUTER CASING form lls
FROM DMTw RT L a licable
MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. 51 ft- 6.25 in. #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal,closed-loop)
FROM
2.Well Construction Permit#: 2021—21 620-9-1 1 260 ft. TO ft DIAMETER THICKNESS MATERIAL
List all applicable well permits(i.e.County,State,Variance,b jection,etc.)
rt. ft. in.
3.Well Use(check well use): tx'SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) RlResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑bri ation 0 ft' 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
El Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL.PACK if a licable'
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwatcr Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20:DRILLING LOG,attach additional sheets if oecess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 51 ft. OVER BURDEN
5-04-2022 51 tt• 585 tt• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: rt. tt. a " _9 v " .� ".? cl 1
Huges, Douglas C ft. ft. t
Facility/Owner Name Facility ID#(if applicable) 201
ft. ft.
445 Big Mountain Rd. Cullowhee
ft.Physical Address,City,and Zi
Jackson y P 2IREMARKS
7544-40-3317
M
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certifieation:
(if well field,one IaVlong is sufficient)
N W &I L 05/10/2022
Signature of Certifi Well Contractor Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo 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 of the
repair under#21 remarks 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: construction details. You may also attach additional pages if necessary.
For multiple injection at-non-water supply wells ONLY with the same construction,von can
submit one form. p SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 585 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
Ifwarer 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Supply Injection Yield(gpm) 3 Method of test: RIG PP Y& lection 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 county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013