GW1-2022-10178_Well Construction - GW1_20221110

I
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This fin in can be used tix single or multiple wells t
I.Well Contractor information:
Kolby Mitchell Sawyers F4.WATER ZONES ( ;
FRODI TO DESCRIPTION
Well Contractor Name
rt. ft. i
4471-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased(we11s OR LINER(if a' licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 It. 150 fr• 6.25 1 i" #21 1 PVC
Company Name 16.INNER CASING OR TUBING eotlfermal closed-loop)
JCH-004W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. i in.
List all applicable well permits(i.e.Countp,State. Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.l
❑A nricultural ❑Municipal/Public
❑Geothemlal(Heating/Cooling Supply) El Residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑ln-ication 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Nlon itori ng ❑Recovery
I jection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(ifapplicable
FROM TO MATERIAL EMPLACEMENT METHOD
❑aquifer Storage and Recovery ❑Salinity Barrier tt ft '
❑ m Aquifer Test ❑Storwater Drainage
ft. ft.
❑Fxperintental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/reck type,gnin sae,etc.
❑Gcothennal(Heating/Cooling Return) ❑Other(explain under 421 Re]marks) fr' 50 tr• OVER BURDEN
9-23-2022 50 tr• 905 rr• GRANITE
4.Date Well(s)Completed: Well iD#
ft. ft.
5a.Well Location:
Robert & Lucy Hites ft. rL
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. O
2022
Roselyn Park Drive Waynesville, NC 28785 ft. «.
Infwwwti
Physical Address,City,and Zip 21.REMARKS
DiVa
Haywood 7697-76-8568 Hydro-Fracked 1/2 GPM
COLrmV Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification-
(if well field.one Iat/long is sufficient)
N W 10-27-2022
Signature of Cerlifi Well Contractor i I Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this jorm,I hereby certq( that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC,02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo cony gfthir record has been provided to the well owner.
l!this it a repair.Jill out known well consinrctiun in(ornnation and explain the nature ofthe
repair under#21 remarks section or on the back of this jornn. 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: 1 construction details. You may also attach additional pages if necessary.
For multiple irgection in non-water smpph wells ONLY with the sane construction,you can
s„1„nit One fia,m SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 905 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Fm-multiple wells list all depths i(different(example-3@200'and 2@100') construction to the following: i
I
10.Static water level below top of casing: 280 (ft,) Division of Water Resources,Information Processing Unit,
nwicr/eve/is above casok.use + 1617 Mail Service Center,Raleigh,NC 27699-1617
f
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.c.auger.rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1/2 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form'within 30 days of completion of
131).Disinfection type: PILLS Amount: 35 well construction to the county health department of the county where
constructed. I
Pura»GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013