GW1-2021-06220_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells 400
1.Well Contractor Information:
Kolby Sawyers � � _ 11d\ FROM w R�o�s
} FROM TO DESCRIPTION J
Well Contractor Name ft. ft.
C'�.
4471-A
NC Well Contractor Certification Number ,6,rJ1 ,eG�O 15.OUTER CASIN6 f6ir multi-eased,veIts OR)INER'if a` `livable
FROM TO DIAMETER THICKNESS MATERIAL.
CLYDE SAWYERS & SOI�9�1`/O PUMP INC +1 ft. 1101 ft- 6.25 in. #21 PVC
Company Name =I6,JNNER CASII±IG OR TUBING eutherimal:closed
NRH-228W 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): 173SGREENF _ - -
Water Supply Well: FROM TO DIAMETER'� SLOT SIZE THICKNESS MATERIAL-
ft. ft. in:
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) BResidential Water SuPP1Y(single) ft. ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) ,�18.GROUT z,• . .,:_.,- -. - _
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation ,,19'SANDIGRA1ELIPACK'(if a "`•caabkj,.; ) _:_ . ..
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
24:"DRILLING LOG attach additionaI sheets if uecess ;
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soil/rock type,grain s' etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 101 ft. OVER BURDEN
05/17/2021 101 ft- 485 ft- GRANITE
4.Date Well(s)Completed: Well ID#
ft. tt.
5a.Well Location:
Sarah Young
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
121 Harley's Cove, Waynesville ft. fL
Physical Address,City,and Zip
s21.4EMARiZS." r..
Haywood 8710-53-8393
County. Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifrc on:
(if well field,one]at/long is sufficient)
05-18-2021 N W
ignature of e t Well Contract Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,I hereby certifv that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or I5A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature of the
repair under#21 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 multiple injection at-non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:485 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@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,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6.25 (in.) 24b. For Infection 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
j
13a.Yield m 4 Method of test- RIG. 24c.For Water Supply&Injection Wells:
(gP ) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 30 well construction to the county 6alth 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