GW1-2023-02854_Well Construction - GW1_20230418

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers cl >nAzlvR:z�ril
FROI\I TO DESCRIPTION
Well Contractor Name
4471-A
NC Well Contactor Certification Number
150(1 i ER CdSING faismtilti case[)netts iOR L'iNERE if a" Itcatite' :M
FROM TO DIAMF,TF.R THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. 52 ft 6.25 in. #21 PVC
Company Name 1b„INVEl2GiASIjYC,.tlRa1t1B11SG, e&iitetatutclosed=tov`
JMQ-280W FROM 1'0 DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: et. ft. in.
List all applicable well permits(i.e.Counry,State,Variance,Injection,etc.) ft. fr. in
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERL4L
in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft. ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) 1$..`GRU[1T' -c�"r .' F,M .. F.M�� ...,.. �':
FROM TO MATERIAL PLACENT METHOD&AMOUNT
❑hri ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
it. rt. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well:
�.. ...;
❑Aquifer Recharge ❑Groundwater Remediation �49(wSAND/CRAVE PAGK>ifa ' ca 7e
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. it.
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
26 bRTU77NN(:TC1G,at(aclir"aiJdltioiiaTsheetsifiecessaiY`,.
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soll/rock tvp a grain size,etc.)
❑Geothermal (Heating/Cooling Return) ❑Other(explain under#21 Remarks 0 ft' 52 fr OVER BURDEN
12-20-2022 52 ft 165 ft GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location: rt. ft. -` -& ,lti 1!sm v
Henry Rathbone ft. ft. 1
Facility/Owner Name Facility ID#(ifapplicable) u�
102 Silvers Cove Road Clyde, NC 28721 ft.ft. «. _
Physical Address,City,and Zi
ys� t}5 P 4;21 REMARK`5.3°x-'�cn��3 ��. ���; x�€.'�`��� �,u'��si; •�,
Haywood 8730-47-2649
County Parcel Identification No.(P1N)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N `(t 1-10-2023
Signature of Certify ell Cua[ractor I Date
6.Is(are)the well(s): RPermanent or ❑Temporary By signing this form,I herehv certify that Nye r+rills)ivas(were)constructed in accordance
ivith 15A NCAC 02C.0100 or 15A 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 N•41 construction information and explain Nte mature of the
repair tinder#21 remarks section or on the back aJ'this firm. 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 multiple injection or non-water supply welly ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 165 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths•iJ'djf ereni(erample-3 dt 00'and 2(a1001 construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
If water 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: construction to die 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)
15 Method of test: RIG 24c.For Water Supply&Injecti nn Wells:
Also submit one copy of this form within 30 days of completion of
PILLS
13b.Disinfection type: Amount• 20 well construction to the county li ealth department of the county where
constructed.
Foray GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013