GW1-2021-06784_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
KOLBY SAWYERS FROM WATER (- :-
FROM TO DESCRIPTION
Well Contractor Name -
4471-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a""licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 115 16.25 i" #21 1 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
WP21-032 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in,
List all applicable well permits(i.e.Counga.S'lale,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. fL in.
❑Agricultural ❑Municipal/Public
in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPIY(single)❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft' 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
f[. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG°attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sin,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 f` 115 f` OVER BURDEN
6-10-2021 115 f` 285 f` GRANITE
4.Date Well(s)Completed: Well ID#
rt. rt.
5a.Well Location: ft. R. _
SCOTT&ANNA OWNBEY ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) .�.
ft. ft. a
561 RED BARN ROAD BREVARD, NC 28712 ft. ft.
11
Phvsical Address,City,and Zip 21.REMARKS
TRANSYLVANIA 8575-50-9704-000 3tito't�� r�c,io�
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 6-24-2021
Signature of Cert ed Well Con c r Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certij�that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofthis record has been provided to the we//owner.
l f This is a repair,fill oul known well construction information and explain the nature of the
repair wider 2l remarks seclion or oil the hack of oins 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.
l�'nr mtdliple u jeclion or non-waler supply wells ONLY with the same construction.you can
SUBMITTAL INSTUCTIONS
.submit one.lorm.
9.Total well depth below land surface: 285 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
bor multiple wells list all depths{/different(example-3 200'and 2 a I00') construction to the following:
10.Static water level below top of casing: 40 (ft•) Division of Water Resources,Information Processing Unit,
if ualer 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,INC 27699-1636
13a.field(gpm)
4 Method of test RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 25 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
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