GW1-2022-08030_Well Construction - GW1_20220909

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NORTH CAROLINA
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WELL CONSTRUCTION RECORD (GW-1 )
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Form GW-1 Well Construction Electronic Form
North Carolina Department of Environmental Quality
Division of Water Resources
November1
Submission ID#
G W 1-2022-08030
Are you submitting a scanned form?* Yes
No
CONTACT INFORMATION
.......................................................................................................................
Email Address*
Contact Name* haley.thompson@byerswelldrilling
Haley Thompson com
Is this a revision to the form you have previously submitted?*
Yes No
WELL CONSTRUCTION INFORMATION
.................... ................... ................... ................... ............... .......... .................. ................... ................... ................... .....
1.Who is installing these wells?*
Owner Well Contractor
1.Well Contractor Information:
........ ......... ..... ......... ......... ......... ......... ..... .........
Certiticate# Cert Level First Name Last Name Company Name
3131 A LON DILLARD BYERS WELL DRILLING, INC.
2.Well Construction Permit#:
.....................................................................................................
1225
List all applicable well construction permits(i.e.Monitoring Wells,UIC-Underground Injection Control,CCPCUA-Central Coastal Plain Capacity Use Area,County,
etc.)
What type of well is this?* Injection Well Non-Water Supply Well
Water Supply Well(includes irrigation wells)
3.Water Supply Well* Geothermal (Heating/Cooling Supply) Industrial/Commercial
Irrigation Municipal/Public/Community
Residential Water Supply(single) Residential Water Supply(shared)
Wells> 100,000 GPD
4.Date well was completed and ID#
Date Well Completed* Well ID# Well Yield

8/15/2022 5
(gallons per minute)"
5.Well Location
Facility/Owner Name*
Larry Sorgen Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Clay
Physical Address* Street Address
1198 McDonald Rd.
Address Line 2
City State/Province/Region
Hayesville INC
Postal/Zip Code Country
28904 USA
Latitude* 34.9930900000 Longitude*83.8378900000
Decimal degrees Decimal degrees
........ ................ ......... ........................... ........................... ......... ......... ......... ...................
6.Is(are)the well(s):* Permanent Temporary
7.Is this a repair to an existing well:* Yes • No
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.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a.Indicate TOTAL NUMBER of wells drilled: 1
9.Total well depth below land surface: (ft.) 9a.What is the depth of the casing from ground
625 surface?
For multiple wells list all depths if different 25
(example-3@200'and 2@100') in feet
10.Static water level below top of casing: (ft.) 11.Borehole diameter:
40 6.25
If water level is above casing,use"+" in inches
12.Well construction method:
Auger Air Rotary Cable Tool
Direct Push Mud Rotary Rotosonic
Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gpm)
5 13a.Method of test:
If applicable Air
13b. Disinfection type:* 13b.Amount:*
Chlorine 20 oz

14.WATER BEARING/FRACTURE ZONES
From To Description
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
0.00 20.00 6.25 PVC
in feet in feet in inches
0.00 25.00 4.00 PVC
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
in feet in feet in inches
18.GROUT
From To Material Emplacment Method&Amount
0.00 25.00 Concrete Gravity
in feet in feet
19. SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
in feet in feet
20. DRILLING LOG
From To Description(color, hardness,soil/rock type,grain size,etc.)
0.00 15.00 Clay
in feet in feet
15.00 20.00 Granite-Set Casing
in feet in feet
20.00 25.00 Granite-Set 4"Casing
in feet in feet
25.00 625.00 Granite-5GPM
in feet in feet
21. Remarks
Was not able to over ream due to hard rock.Grouted between 4"and 6"casing to seal off from groundwater
contamination.
22.Site diagram or additional well details:
You may upload additional well construction information here.
Sorgen Larry-Variance Application for Irrigation Well .pdf 681.5KB
pdf only

CERTIFICATION INFORMATION
....................................................................................................................................
* By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C.0100 or
15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to the well owner.
23.Certification
Signature of Certified Well Contractor