GW1-2022-09527_Well Construction - GW1_20221017

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This Ibrm can be used f'or single or multiple wells
I.Well Contractor information:
Kolby Mitchell Sawyers FRO WATER ZONES DESCRIPTION
Well Contractor Name ft. ft. j
4471-A ft. ft.
NC Well Contractor Certilication Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a livable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 83 ft. 6 1/8 ' in. #188 Steel
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
SAS-203W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable hell permits(i.e.County,State.Variance,h jection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE 'THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public rt. ft. in.
❑Genthermal(Heating/Cooling Supply) El Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrieation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquiler Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. rt.
❑AquitcrTest ❑Stonmvatcr Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessar
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rt 83 ff OVER BURDEN
10/3/2022 83 rc 225 rc GRANITE
4.Date Well(s)Completed: Well ID#
rc. rt.
5a.Well Location:
Gustavo Rebola
Facility/Owner Name Facility ID#(if applicable)
ft. ft. OCT 1 n
2072
Brennan Road Maggie Valley, NC 28751 ft. ft.
Physical Address,City,and Zip 21.REMARKS l i�+ift:.,.: :i t'i'•^;: •;,; (;C;4
Haywood 7677-20-2643
County Parcel Identification No.(PM)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W 10/3/2022
Signature orCertiL Well Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby certw 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
7.Is this a repair to an existing well: ❑Yes or ONo cope gfthis record has been provided to the well owner.
Ifihi.s is a repair,fill out known well construction injoramtion and explain the nature ofthe
repair under#21 remarks section or on the back ol'thisform. 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 if necessary.
For multiple injection or non-n•amr supp(c wells ONLY with the:sane construction,you can
Submit one form. 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 multiple irells list all depths ifdglcrent(example-3 a 200'and 2 a 100') construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
II•nrater lcrel 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:n
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
13tt.Yield(gpm) 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 health department of the county where
constructed.
Forth OW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013