GW1-2022-09528_Well Construction - GW1_20221017

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers FROM TO DESCRTPTION
Well Contractor Name
4471-A ft. ft.
NC Well Contractor Certification Number 15,:QliTER,CA5lNG'formuld-caseitlwetis:OR-LINEK 3fa LicaUk
FROM TO DIAMFTF.R THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 180 ft. 16.25 in #21 PVC
Company Name t6.`INNER:CASINGOR:-TUBJNG: eofhermauelosed lobe)
MCM-324W FROM to DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. to
List all applicable well permits(i.e.Couna,State,Yariance,Injection,etc.) ft fr. in
3.Well Use(check well use): I7:=SCRSEI� �:
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS hIATERTAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Coolin Supply) ElResidential Water Supply(single) ft. it. m
(H � g PP Y) PP Y g
❑lndustrial/Commercial ❑Residential Water Supply(shared) .
�K GROUT .a
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri gation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
Ct. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation :I9.=SiND[GRAT€ET PeA6K:_da "`able ...._. ,_
FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stomtwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
rOf-
❑Geothermal(Closed Loop) ❑Tracer TO DESCRIPTION color,hardness,soil/rmk ri e rain size,etc.)
❑Geothermal(Heatin Coolin Return ❑Other(ex lain under#21 Remarks 80 ft. OVER BURDEN
9-30-2022 305 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft.
5a.Well Location:
`Kelly Burnette
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Farmhouse Road ft. ft.
Physical ical Address,City,and Zip
P
Haywood 8667-87-3533
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 W Cit 10/03/2022
Signature ofCertifiyVell Contractor Date
6.is(are)the well(s): ❑�Permanent or ❑Temporary By signing this form.1 herehY certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 nr 1 SA NCAC 02C.0200 Nell Conshvction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction informution and explain the nature of the
repair under#21 remark,section or on the back ofnhis firm. 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 ifnecessary.
For multiple injection or non-water supply wells ONLY with the.same construction,you can
.submit one form. SLBMITTAL INSTUCTIONS
9.Total well depth below land surface: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiJjerent(example-3(d200'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,
If wetter 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: constriction 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
4 RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 35 well construction to the county health department of the county where
constructed. ,
Forte G W-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013