GW1-2023-01990_Well Construction - GW1_20230227

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers FRO� TO TEIi7AhiES_=<>::<< DEsCRrP; O
Well Contractor Name ft. ft•
4471-A
NC Well Contractor Certification Number t5's':OGTE1t:C"ING,formulif;cs wetls Olt<tIrVECt:'if a"'1t%atile
FROM TO DIAMETER TMCKNF.SS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 120 n- 15.25 #188 Steel
Company Name tds;INNER:CASI3VG;OA-:TlTB13V0 4oftierriim4etose1i=10f1 < ;s:: 3-z `'<f?=<:=':":
2,Well Construction Permit#:
2021-22255-9-12150 FROM O tt, DIAMF:1'ER to THICKNESS MATERIAL
List all applicable at!ll permits(i.e.County,State,Yar•iance,Injection,etc.) ft. ft. in.
3.Well Use check well use): CRE
Water Supply Well: FROM To < DIAMETER SLOT SIZE THICKNESS 111ATERiAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Coolin Supply) EIResidential Water Supply(single) in•
ti GROUT;:=;1'ss:i
❑IndustriaVCommercial ❑Residential Water Supply(shared) FROM TO MATF.RiAL EMPLACEMENT METHOD&AMOUNT
❑lrr9 ation 0 ec. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. fr.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation `.19:SANDIGRAYEGPACK ifa cable f »:>F<::<=:<.?s ::r=>zs:-x•::::-
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
:20�DR1>vL1NCi�C1G`a[faelt'addifitiiiat`stieetsifiiceessa';' '``���`:t``-��`�`�?-'
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTTON color,hardness,soiVrock ri e grain size,etc.)
❑Geothermal Heatin ooLing Return) ❑Other(explain under#21 Remarks) 0 ft. 20 fr.
01-02-2023 20 f`' 95 ft.4.Date Wells)Completed: Well 1D# 95 rt. 325 ft OVER BURDEN
5a.Well Location: ft. ft. --�
Morgan, Robert ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. t2, ( 2023
Yonder Way, Cullowhee
Physical Address,City,and Zipa;
-::2t�RF.MARKS�.:.u. c<.:.:.�:.;:::;.;::.:<-� :;.:.:•.;:::::::::-:rri;�.�or"x;�==--�+v-s:+::s:::.:�:..,,...,..<.<-::-:-:-;--:
Jackson 7568-51-7925 20'to 95'is 6.25#21 PVC
County Parcel Identification No.(PIN) This well was self certify
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(ifwell field,one lat/long is sufficient)
N W
01-03-2023
VV—" cso !1 ",A=
Signature ofCcitifliMell Contractor i' Date
6.is(are)the Irell(s): OPermanent or ❑Temporary By signing this form,1 herehv vertify�that the well(s)uw(were)constructed in amOrd(Inre
with ISA 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 ONo copy of this record has been provided to the well owner.
If this is a repair,f/l out Anuna well construction information and explain the nature of the
repair ender 021 remarks,section or on the back ofthis 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 ifnecessary.
For rnultiple injection or non-xater supply wells ONLY with the same consstructiun,you can
.submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 325 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths it diJjt rent(erample-3@200'and 2(a100) construction to the following:
30 Division of Water Res lourees,Information Processing Unit,
10.Static water level below top of casing: (ft.)
Ifwater level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 276994617
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.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service C enter,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method of test' RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 35 well construction to the county Health department of the county where
constructed. 4
Form GW-1 North Catalina Department of Environment and Natural Resources-Division of Water! Revised August 2013
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