GW1--04495_Well Construction - GW1_20230713

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Sawyers 114 x rl IRAs is :a .. . . WA
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
4471-A rL ft.
NC Well Contractor Certification Number 2iV(iDttit. ING(fartnAlii `h t:sells)flit 1NGlt.(I le leffI t .;A
CLYDE SAWYERS&SON WELL&PUMP INC FROM TO DIAMETER THICKNESS MATERIAL
+1 ft 82 ft* 6.25 1° #21 PVC
Company Name t1F'11)wit;CASI14�`(iil.T[JStI'i',{k4tieru�ataclr`i� ps): ,�„' ';
2.Well Construction Permit#: 2O2 —224 3-9— z16
9H9 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fL ft. in.
3.Well Use(check well use): fL ft. in
Water Supply Well: 4A7AcingE NA a ',= "„W -',3g .,
Pp FROM TO DIAMETER SLOT SIZE YthcloYEss MATERIAL
Ali Agricultural E3Municipal/Public ft: ft. in.
IGeothermal(Heating/Cooling Supply) Ea Residential Water Supply(single) ft. ft. in.
iindustrial/Commercial E3 Residential Water Supply(shared) p o{;r�,
+e"105"�1�V11tiS��a+y5�l',K��+�� v��`...�..�L+xzi'd''..t r. !tq,t
I irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. Bentonite Pumped
II I Monitoring Recovery ft. ft. Cap Top with Bentomite chips
Injection Well:
ft. ft.
*1Aquifer Recharge EjGroundwater Remediation
1.9 5'iYl?tll/fG`ItA'#tE1IrXtK(iF.*p114ifiblW�.z .. "> '` I s`'`.'
al Aquifer Storage and Recovery Ei Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
$iAquiferTest r3 Stonnwater Drainage ft. ft.
*I Experimental Technology 0 Subsidence Control ft. ft.
!Geothermal(Closed Loop) OTracer =20'DitHitill t'T:C1tax(at£`acFi'addictait3 shee'iiIEmressgt'i �' '
FROM TO DESCRIPTION(color.hardness,soil/rock type.grain size,etc.)
1 Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) r n
0 ft 82 ft OVER BURDEN ;'rn K „`• l
4.Date Well(s)Completed:6-7-2023 Well iD# 82 ft 305 ft' GRANITE ', �' .-, u my
5a.Well Location: ft. ft. 1+J1`_ 1 ZL L3
Chesater D Dilday ft. ft. rr5,5,73 L[i
Facility/Owner Name Facility ID# if a livable ft. ft. inv:tl AN Li NG
Vd;�.-
145 Leyla Court Sylva, NC 28779 ft. ft.
Physical Address,City,and Zip ft. ft.
Jackson 7652-20-9925 l RE iAx ., .r : ``tom.
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W 7-5-2023
6.Is(are)the well(s)OPermanent or ®Temporary Sigma a of er edth untractor Date
By signing th farm,I hereby cerrijj'that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: D Yes or x No with 15,4 NCAC t)2C.0100 or 15A NCAC(I2C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#2I remarks section or on the buck of this form.
23.Site diagram or additional well details:
8.For Ceoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d erent(example-3 ,200'and 2@i00') construction to the following:
10.Static water level below top of casing: 50 (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 Injection Wells: In addition to sending the form to the address in 24a
ROTARY above, also submit one 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) 4 Method of test: RIG 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: PILLS Amount: 30 completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016