GW1-2022-10175_Well Construction - GW1_20221110

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 DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
t5,.(311y1✓tR4 ASiNtx.toraiutt�catleil:wells T31FI.l1VRft s itea7ak
NC Well Connector Certification Number
FROM TO DIAMF.TF.R THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 120 ft- 16.25 i" #21 1 PVC
Company Name
DSG-010W FROM DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,e(c.) ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO I DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Murlicipal/Public it. ft. in.
❑Geothermal(Heating/Coofing Supply) OResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) lg=DgDUT u.. �.._ .. ..
FROM TO MATERIAL EMPLACEMENT MF.THOI)tti 4MOIJW
❑Trri ation 0 ft 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediatiou ..12.; )SIYi?/DR9:�a LT,AitF3�_ �._ .<b1e,_�___ _�•.._..�.��F � _ `FRODI TO MATERIAL EMPLACEMENT METHOD _._.
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20:i)B1LT3!i bG iiftaeLadtl aaalslteets .anetessh
❑Geothermal(Closed Loop) ❑TTacer FR0111 TO DESCRIPTION color,hardness,soil/mk type. ram size,etc.)
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 ft. 120 ft• OVER BURDEN
10-06-2022 120 e• 605 ft• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
ft. ft.
Pamela Kennedy ft. ft.
Facility/Owner Name Facility ID#(if applicable) n 202
618 Glades Road ft. �J
ft ft
Physical Address,City,and Zip inf�f
Haywood 8649-65-2822
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification-
(if well field,one tattlong is sufficient)
N W 10/06/2022
Signa[ureofCatiS a Contractor i Da[e
6.is(are)the well(S): OPermanent Or ❑T¢mporary By signing this frnm,l herehy certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC'02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy of this record has been provided to the well owner.
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. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the some construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 605 —(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiIferew(example-3(aj200'and 2(a1001 construction to the following:
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
I)'water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
I
I1.Borehole diameter: 6.25 (in.) 24b.For Infection 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
10 RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: Also submit one copy of this foim within 30 days of completion of
13b.Disinfection type: PILLS Amount: 35 well construction to the county health department of the county where
constructed. 14
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Form OW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013