GW1-2023-00623_Well Construction - GW1_20230105

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WELL CONSTRUCTION RECORD For Internal Use ONLY: i
This form can be used for single or multiple wells I i
1.Well Contractor Information:
Derrick Heath Sawyers FROM TO -y DE5CRIpTfO.,
Well Contractor Name ft. ft. I I
2436-A
NC Well Contractor Certification Number f9'M ER'CTO formnhS-caAei#welis.01T IN NE SS ttca AT
FROM TO DiAMF.TF.R THICKNESS 11fATF.RiA1
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 105 ft 5.25 ! #188 STEEL
Company Name tb.:INN£RGASING--OR 1UB1NG egfhetTnuhc(osed lao
SAS-251 W FROM TO DIAMFIKR THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. to
List all applicable null permits(i.e.County,State,Variance,Injection,etc.) ft ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAPIETER SLOT SIZE THICKNESS AATERIAL
n.
❑Agricultural ❑Municipal/Public ft. ft. i
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:D130[IT._
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑itri ation 0 ft' 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
FROM TO MATERIAL ENIFLACEME.NT METHODm
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Storniwater Drainage
et. ft.
❑Experimental Technology ❑Subsidence Control k_
20DTt1G1:TNG:Ef.1G:attaeliaddttiuiialsheets:ifiecessa -'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness•soilfrock type rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 105 ft. OVER BURDEN
11-18-2022 105 ft- 485 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: rt. ft.
W. Scott Forga
Facility/Owner Name Facility ID#(if applicable)
611 Big Cove Rd ft. ft.
Physical Address,City,and Zip
Haywood 8603-47-2907
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certitication:
(if well field,one lat/long is sufficient)
I
N W 11-23-2022
Signature of ertified Well CTutractivDate
6.is(are)the well(s): OPermanent or ❑Temporary By sihning this fe)rm,I here?v certify that the wells),vas(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 sA NCAC 02C.0200 N'el1 Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided ro the well owner.
If this is a repair.fill out knuxn well construction information and explain the nature of the
repair under#21 r•emarlo•section or on the back of this form. 23.Site diagram or additional well details: y
You may use the back of this page to provid ddiiiorai yv H s4ekdeflttls r`well
8.Number of wells constructed: construction details. You may also attach addition'ai pages?necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can NZ3
.submit onefor•m. A pG SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:485 (ft.) 24a. For All Wells: Submit this form within 30 dax§ o�Fpmp[eTidn�ocll
For multiple wells list all depths if(h#erent(example-3@200'and 2(ae100D construction to the following: j, 1niv+�° `t j'r�✓�=
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I,
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.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
13a.Yield(gpm) 6 Method of test: RIG
24c.For Water Supply 8t Injection Wells:
r�
Also submit one copy of this form within 30 days of completion of
PILLS
13b.Disinfection type: Amount: 20 well construction to the county�he i alth department of the county where
constructed.
Farm GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013