GW1-2022-07737_Well Construction - GW1_20220819

WELL CONSTRUCTION RECORD For Internat Use ONLY:
This firm can be used for single or multiple wells
1.Well Contractor information:
14.WATER ZONES
Derrick Heath Sawyers FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
2436-A
NCWeIIContracturCertificationNumber 15.OUTER'.CASING for multi-cased Swells)
ORLINERifa ticable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 40 ft• 6.25 in. #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
JCH-014W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Count),,State.Variance,lutection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Mtmicipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in•,
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.`GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑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
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20 DRILLING LOG(attach addition al sheets ff necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/mck type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 0 e. OVER BURDEN
6-29-2022 40 rc• 225 fi- GRANITE
4.Date Well(s)Completed: Well iD#
ft. ft.
5a.Well Location:
David Wilson G
ft. ft.
Facility/Owner Name Facility ID#(ifapplicable)
1840 Mauney Cove Road Waynseville, NC 28786 ft rt IJr
Physical Address,City,and Zip 21.REMARKS
Haywood 8606-55-2078
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)
7-5-2022
N W
Signature of ertified Well C6ntractoof, Date
6.Is(are)the well(s): 21'ermanent or ❑Temporary By signing this form,I hereby certiifv 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 KNo copy of 1his record has been provided to the well owner.
I/'this is a repair,.lill out known well construction infitrmalion and explain the nature ofthe
repair under#2/remarks section or on the back q/'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 ifnecessary.
For multiple injection or non-water svpinv wells ONLY with the same construction.you can
submit one/orrn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface• 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For rnttlliple wells list all depths ifd/lferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing• 50 (ft) Division of Water Resources,Information Processing Unit,
If hater 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.anger,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
13u.Yield(gpm)
5 Methodof test:
RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this foi•rn within 30 days of completion of
13b.Disinfection type: PILLS Amount• 25 well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water.Resources Revised August 2013