GW1-2022-07769_Well Construction - GW1_20220822

WELL CONSTRUCTION RECORD For Internal Use ONLY: j
This torm can be used for single or multiple wells
I.Well Contractor Information: f
14.WATER ZONES
Kolby Mitchell Sawyers FROM '1.0 DESCRIPTION
Well Contractor Name
ft. ft. '
4471-A it. it.
NC'Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a Geable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft 58 ft 6.25 ! #21 PVC
Company Name 16.INNER CASING OR TUBING eother at closed400
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 202 1-2 1 643-9-1 1 51 4 ft fA In
List all applicable well permits(i.e.County,State. Variance,hyection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM '110 DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in
❑Agricultural ❑Municipal/Public
ft. tt. in:
❑Geothernal(Heating/Cooling Supply) ElResidential Water SuPP1Y(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Initiation 0 rt. 20 {t 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 EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwatcr Drainage
tt. ft.
❑Fxperiniental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiVrock type,gnin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 R. 58 tt. j OVER BURDEN
$-5-2022 58 ft- 105 ft- GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location:
Heather Watson/Brendon Deitz
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. it.
114 Brayer Lane Cullowhee, NC 28723 ft. ft.
Physical Address.City,and Zip 21.REMARKS
.Jackson 7660-00-3037
Coumv Parcel Identification No.(PIN)
51).Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one]at/long is sufficient)
N W 08/10/2022
Signature ofCertifi Well Contractor Pa i
e•
6.Is(are)the well(s): 2Permanent or ❑Temporary Br signing this Jonn,!hereby certify r6ahthe well(s)las(were co tsr{u d c4ttt'dance
With 15A NCAC 02C.0100 or 15A NCAC 02C.0200 We I Cori c•ti St(mdu'. and chat a
7.Is this a repair to an existing well: ❑Yes or ONo cape gfthis record has been provided to the well owner.b jJ tI �02,,-
Il this is a repair.Jill out known well construction injrrniation and«rplain the nature of the
repair under#2l remarks section or on the back ojrhis form. 23.Site diagram or additional we11 details:. s. r�� �F
You may use the back of this page to proVt8C" t r3w (�Aftwell
8.Number of wells constructed: construction details. You may also attach additional s d ary.-
Far nnulniple injection or non-water.supply wells ONLY with the same construction,you ran
subinii one f6rnn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 105 (ft.) 24a. For All Welts: Submit this form within 30 days of completion of well
For muhiple yells list all depths ifdijjcrent(exannple-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 20 (ft,) Division of Water Resources,Information Processing Unit,
If venter level is above easing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b. For Injection 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.) j
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1
13a.Yield(adp m) 30 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
PILLS well construction to the county health department of the countywhere
13b.Disinfection type: Amount: 20 j
constructed. I
Form 0W-I North Carolina Department of Environment and Natural Resources-Division of WaterResources Revised August 2013