GW1-2022-07935_Well Construction - GW1_20220823

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Derrick Heath Sawyers FROM ATI�R TODESCRIPTION
Well Contractor Name ft. ft.
2436-A ft.
NC Well Contractor Certification Number 15.it31)TERCASLtWGi forifiuld casedlvells UR!LI\ER ifa "licable
FROM TO DiAMF,T'F.R THiCKNF.SS MATERTAI.
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 71 ft. 5.25 i" #188 STEEL
Company Name CANNER CA$tNG OR TUBING "euthermal; bsed luo'`
WP22-023 FROM 10 DIAMETER IIICKN6SS PIAI'ERI L
2.Well Construction Permit#:
ft. ft. in.
List all applicable well permits(i.e.Countv,Slate,Variance,Injection,etc.)
it. ft. in.
3.Well Use(check well use): 17 SCREEN ..r_
Water Supply Well: FROM To I DIAMETER SLOT SIZE THICKNESS MATERIAL
fL❑Agricultural ❑Municipal/Public ft. ih.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) 38 GROUT ' .. ..
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑ht; ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. tt.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.:SAND'/GIiAVL�PAGE ble ..
❑Aquifer Storage and Recovery ❑ MATERIAL
FROM TO AL EMPLACEMENT METHOD
Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
2011RILLINC"LOG atfaeb'additi2itbtsfieetsifatecessery
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type. rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(ex lain under#21 Remarks) 0 ft' 71 ft' OVER BURDEN
07-22-2022 71 fr• 625 tt• GRANITE
4.Date N'eil(s)Completed: Well ID#
5a.Well Location: ft. ft.
Timothy Phillips ft. ft. AUG ,, Z022
Facility/Owner Name Facility ID#(if applicabie) R. ft
TBD Crab Creek Road 'nt"f''" F�
fL (t• r.�:kd�130G
Physical Address,City,and Zip 21;REM1fARKS';
Transylvania 9517-33-4597-000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N fir , 7-22-2022
Signature of ertified Well Courrac•t Date
6.Is(are)the ivell(s): ❑✓Permanent or ❑Temporary By signing this form.1 herehv certtfy',lhut the wells)wvs(were)constructed in arew-dance
With 15A NCAC 02C.0100 ar 1 SA NCAC 02C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided to the well owner.
If this is a repair,fill out known w-ell constructiun infurmatiun and explain the nature ufthe
repair under 921 remark,section or an the hack r f this,form. 23.Site diagram or additional,Jell details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages ifneccssary.
For multiple injection or non-water supply wells ONLY with the sume construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 625 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iij i# ireni(example-3(a�200'and 2(a,100') construction to the following:
10.Static water level below top of casing. 30 (ft.) Division of Water Resources,Information Processing Unit,
ff iwler level is above casing.use"+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection 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) 2 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• 20 well construction to the county jhealth department of the county where
constructed. j
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Form G W-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013