GW1-2022-06309_Well Construction - GW1_20220628

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolb Mitchell Sawyers Y Y 4.'ATERZ QI S ..
DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. rt.
NC Well Contractor Certification Number M"OUTER:CASING For zriultr cased wells OR'GINER „
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 195 ft- 1 6.25 #21 1 PVC
Company Name 46,INNER"CASING OR-'FUBIN6, 'euthermal closed-loci
Willa J.. D e h a rt FROM TO DIAMETER THICKNESS MATERLM,
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,b jection,etc.)
ft. ft. in.
3.Well Use(check well use): 47.SCREEN.? •i
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling/Coolin Supply) FIResidential Water Supply ft. ft. in.
( g g PPY) PPY
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery,
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19:SANDIGRAKEL.PL>CK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG"attach additional sheetsafaecess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 95 ft. OVER BURDEN
6-08-2022 95 fr• 145 fr• GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location:
Willa J. Dehart _ ;�
Facility/Owner Name Facility ID#(if applicable)
ft. it. J U 2
Dehart Cove, Lot 8
Physical Address,City,and ZipREMARKS�'W_"'
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 06-14-2022
Signature of Certifi Well Contractor Date
6.Is(are)the well(s): ❑✓Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA 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 E]No copy of this 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: 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 one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 145 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(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,
If water 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) 30 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 county where
constructed.
Forte GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013