GW1-2022-07740_Well Construction - GW1_20220819

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This Rwiti can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES' )<
Derrick Heath Sawyers FROM TO DESCRIPTION
Well Contractor Name
2436-A ft.
ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased yells)OR LINER(if a ticable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 85 ft' 6.25 i #21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
SAS-185W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State. Variance,injection,etc.)
in.
3.Well Use(check well use): 17.SCREEN i
Water Supply Well: FROM TO DIAMETER SLOTSILE THICKNESS MATERIAL
ft. rt. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. I in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 D. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental 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.
❑Geothenmal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 85 ft. OVER BURDEN
7-1-2022 85 ft• 325 ft. GRANITE
4.Date Well(s)Completed: Well iD#
e. rt.
5a.Well Location:
Michael Harris ft. ft. ii_Q.—I —
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Mauney Cove Waynesville, NC 28786 ft. ft. AUG 1 9 2Q22
Physical Address,City,and Zip 21>REMARKS L i tic7nc,
Haywood 8606-67-4036
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 WW""Jj� ,s7-8-2022
Signature(ifi7ertified Well C6mracto Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,I hereby certfv that the well(s)was(were)constructed in accordance
With I SA NCAC 01C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or END copy gfihis record has been provided it)ihe well owner.
lfthis is a repair./ill out known well consiruction information and explain the nature ofthe
repair under#21 remarks section or on the back of thisfornn. You
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 ifnecessary.
For multiple injection or non-Crater supph•wells ONLY with the same construction,you can
suhnuit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 325 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple m ells list all depths ifdi(ferent(example-3@200'and 2 a)100') construction to the following:
10.Static water level below top of casing: +1 (ft) Division of Water Resources,Information Processing Unit,
.rater 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
a
m 13a.Yield
(gP ) 15 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: 30 well construction to the county hfealth department of the county where
constructed.
Forma GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013