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HomeMy WebLinkAboutGW1--05614_Well Construction - GW1_20240916 II WELL CONSTRUCTION RECORD For Internal Use ONLY: i' ' This form can be used for single or multiple wells li i 1.Well Contractor Information: Derrick Heath Sawyers 'xa."''`tiCzO s , M�' " ` 4 ` ` w—,4- FROM TO DESCRIPTION Well Contractor Name ft. ft. 2436-A ft. ft. I NC Well Contractor Certification Number x15R tI ER"CAS NGr=(ftirmitlt3 caietlk llg)'OR 4INER(rf''appliei10FeTfK. �„;�„" FROM TO DIAMETER THICKNESS MATERIAL CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. 72 ft. 6.25 i' in. #21 Pvc Company Name cl6 iNl`yERTCASIN'G:t7iRiTl')BiN(r(`t eattie>iltial closed=loop) `r=';'wt,.1„..'"x`i 1 JMQ-310W 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): . .,.LflSl:R GCN�.�'��,'�a.�i:s.�ix ;����.�.3 ���3a>,'����,4 5"..< + .x4r` Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL DAgricultural ❑MunicipaliPublic ft. ft. in., . ❑Geothermal(Heating/Cooling Supply) E(Residential Water Supply(single) ft. ft. in. Z.❑lndustriaVCommercial ❑Residential Water Supply(shared) 1g OR011,. ,c - ' 1 , , O ' 41 z: `>�< ..t 3.,,. FROM TO MATERIAL' EMPLACEMENT METHOD)&AMOUNT ❑irrigation 0 ft. ft Non-Water Supply Well: 20 Bentonite Pumped DMonitoring ❑Recovery ft. ft. Cap Top with Bentonite Chips injection Well: ft. ft. DAquifer Recharge ❑Groundwater Remediation M9WANIVORAMEOFACKlifilijitabliloMM, WitSITIWWVOMM., FROM TO MATERIAL EMPLACEMENT METHOD DAquifer Storage and Recovery ❑Salinity Barrier ft ft. DAquifer Test ❑Stormwater Drainage ft ft l DExperimental Technology ❑Subsidence Control 2U,DRIrLINt";T>fJG•{aitacliptddtttvnatst)ectsifiteeessarv :afriPPYMekin DGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color.hardness,soil/reek type.gram size. etc.) ❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft. 72 ft. , OVER BURDEN • 8-7-2024 72 ft. 485 ft• i. GRANITE 4.Date Well(s)Completed: Well ID# ' ' ft ft. I 5a.Well Location: ft ft JANE KERI HENSON ft. ft. Facility/Owner Name Facility 1011(if applicable) ft, ft. LOT C-4 DRY BRANCH TRAIL CANTON, NC ft. ft. . Physical Address,City,and Zip it:It IVINRti' „ 41t `1'„. MMI,W, t zZ r�"...•- HAYWOOD 8653-73-3340 WELL WAS SELF CERTIFIED 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 8-23-2024 Signature of edified Well Contracto Date 6.Ts(are)the well(s): ❑�Permanent or ❑Temporary Bysi tin this Drop.1 hereby rem that the well(s)was(were)r,r r, h' t n� r re s s f I k.v with 15A NCAC 02C.0100 nr 1 SA NCAC 02C.0200 Well Constru o'Sfttect rd f orb quit a ,.� 7.Is this a repair to an existing well: DYes or IEINo copy of this record has been provided so the well owner. �" ' • L. If this is a repair,fill out known well construction information and explain the nature of the ! ^r repair Corder F21 remarks or on the back a'this_/i,rnr. 23.Site diagram or additional well details: J t J 00 You may use the back of this page'to provide additional well site details or well 8.Number of wells constructed: ' construction details. You may also attach additional pag/hitammtrh.Fifr.r For multiple injection ornon-a'ter.supply wells ONLY with the same construction,you can �`t, submit one forth. Q C SUBMITTAL INSTUCTIONS DI 4,120G 9.Total well depth below land surface:485 (ft.) 24a. For All Wells: Submit this,'form within 30 days of completion of well For multiple wells list all depths ifdi/f rent(example-3(a 00'and 2(u4'100') construction to the following: I. 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 1 II.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY: iIn'addition to sending the form to the address in 24a above, also submit a copy of this form within 30 days of completion of well 12.Well construction method: ROTARY 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 Center,Raleigh,NC 27699-1636 I 20 RIG 24c.For Water Supply&Injection,Wells: 13a.Yield(gpm) Method of test: PILLS ' Also submit one copy of this form within 30 days of completion of 13b.Disinfection type: Amount: 35 well construction to the county het health department of the county where constructed. I Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013 II t p I 1