GW1-2021-01526_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD y,temal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: Iv HR
KOLBY MITCHELL SAWYERSInfi0rmaiti011 Proc
..sA1Q CP.I", "t TO DESCRIPTION
Well Contractor Name
4471-A ft.
�x
NC Well Contractor Certification Number tS,.Qll Efft-CtfittG.tormutti-easellsvet s ORIi13V�Ct. f ltcxlrle
FROM TO. DIAMFTRR THICKNESS ATATF.RIAI
CLYDE SAWYERS AND SON WELL +1 fl. 20 ft- 6.25 #21 PVC
Company Name
t INIl7B.,CA�11V.G.�M0010, ttier,nn nosed-1av
MPH-240W FROM 10 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
ft. I in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft• ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) ..
FROM TO MATERIAL EMPLACEMENT METHOD&.AMOUNT
❑li-ri ation 0 ft. 20 ft. BENTONITE PUMPED
Non-Water Supply Well:
❑Monitoring ❑Recovery
injection Well: ft. ft.
..
❑Aquifer Recharge ❑GroundwaterRemediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
ft. fr.
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
20'Dlt1LLT1�0;�fOG-aftaol ad8lti`aiilsheets Il�eressa :- .::.,: ..:....:
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soitfrock type. rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 20 fr. OVER BURDEN
et. ft.
4.Date Weil 02/11/2021(s)Completed: Well 1D#
20 ft• 125 ft GRANITE
5a.Well Location:
TRISTAN BROWN
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
46 HEGGIE LANE, WAYNESVILLE ft. ft.
Physical Address,City,and Zip
213Z£NIARKS::
HAYWOOD 8607-21-3990
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well Geld,one tat/tong is sufficient)
S CWMA #01
N `,it 02-11-2021
Signs el,,,tied Well Contrait Date
6.is(are)the w'ell(S): OPermaoent or ❑Temporary By signing this jbrm.1 herehv c :Jy that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 14 ell Construction Standards and that a
7.Is this a repair to an existing well: OYes or ❑No copy ofihis record has been provided to the well owner.
If this is a repair.fill uut knuivn well construction in(urmutiun and explain the nature of the
repair tender#21 remarlo•section or on the back e fihis farm. 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-tvater supply wells ONL 1•with the same construction,you can
.submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 125 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi)jerent(example-3(6�00'and 2(a,,100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
I%venter 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 AIR 24aabove, 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
13a.Yield(gpm) 30 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 20 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