GW1--04522_Well Construction - GW1_20230713

•
WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers 14,WATER"ZONEs I ;1
FROM TO DESCRIPTION
PION
Well Contractor Name ft. ft.
4471-A ft. ft. •
15.OUTER'CAStNG'(formutti-case'tlsinllsYOR'LtNER(ifiti licable):°f _
NC Well Contractor Certification Number ._PP -
:
FROM _ TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 64 ft• 6.25 in. #21 Pvc
Company Name .I6,-1NNER4CAS NG031 TUDING(geothermal closed loop)";- v;,°
DGS-035W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance.Injection,etc.) ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft, in.
ft. ft. in.(Heating/Cooling Supply) El Residential Water Supply(single)
❑industrial/Commercial ❑Residential Water Supply(shared) t8:-GRoUT...
FROM TO MATERIAL -EMPLACEMENT.METHOD&AMOUNT
❑Irrigation 0 ft' 64 ft• Bentonite Pumped
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/G12AVELl'ACR.(ifappilicable) . ,,, €•
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
DAquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
,,20,-DRILLING LOG(attacli'additionalts scets if necessart)"? •
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soft/rock type,grain sire,etc.)
+
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft• 64 ft• OVER BURDEN
6/13/2023 64 ft• 365 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
Kent Michaud '7 i'%"- ` e;"'n
ft. ft. ,:-....t,,-'L, V Ia
Facility/Owner Name Facility lD#(if applicable) ft. ft.
1131 Saunook Road, Waynesville 28786 ft. ft. ilk 1 2023
Physical Address,City,and Zip , � r
F21!REMARKS _ 1, ine,i?t a I s , „0.,f*° t,.'/
Haywood 7694-60-0168 This well was self certifar.C -''OG
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W 06/16/2023
Signature ofCertift Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary
Si'signing this Joan,1 hereby corn{/{•that the well(s)was(Were)constructed in accordance
with 1.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ID Yes or ElNo copy of this record has been provided to the well owner.
!(this is a repair,fill out known well construction information and explain the nature of the
repair under 1121 remarks section or on the back of this form. 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 nu thiple injection or non-water supply wells ONLY with the same construction.you can
submit one focus. SU BMITTAL INSTUCTIONS
9.Total well depth below land surface: 365 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Ca/200'and 2@100.) construction to the following:
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
11.Borehole diameter: 6.25 (in.) 24b.For injection 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
RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 5 Method of test:
PILLS Also submit one copy of this form Iwithin 30 days of completion of
13b.Disinfection type: Amount: 2O well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013