GW1--05614_Well Construction - GW1_20240916

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WELL CONSTRUCTION RECORD For Internal Use ONLY: i' '
This form can be used for single or multiple wells li
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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
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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
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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
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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
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