GW1-2021-06557_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD For Imemal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
14.WATERZONEs
HEATH SAWYERS i;
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for mulfi-casedwells OR.LINIZifa licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rr. 56 ft. 6.25 i #21 Pvc
Companv Name 16..INNER CASING OR TUBING(geothermal closed-loci
NRH-254W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
list all applicable sell permits(i.e.County,blare, Variance,Injection,etc.)
ft. rt. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPIY(single) ft. f. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrrigation 0 ft' 20 ft- Bentonite Pumped
Nun-Water Supply Well:
rt. rt.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. 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 ft. 56 fr. OVER BURDEN
9-9-2021 56 tr• 245 rr• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location:
WESLEY RATHBONE
Facility/Owner Name Facility IDN(ifapplicable)
I
PANTHER CREEK ROAD CLYDE, NC 28721 ft. ft. in9U"'
Phvsical Address.City,and Zip 21.REMARKS
HAYWOOD 871-26-0404
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(it\well field one lat/long is sufficient) �1
N W 10-14-2021
Signature ofCertifed Well Contracka
Date
6.Is(are)the well(s): ZPermanent or ❑Temporary By signing this Jorin,I hereby cerliJy that the trell(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 E]No copy oJlhi.s record has been provided to the well owner.
//this is a repair,till out known well construction information and explain the nature of'lhe
repair under 11 remarks.secliun or on the hack q/'thisJnrm. 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.
hitr tntdliple injection or non-tratersupply bells ONLY trilh the.same construction,you can
suhnni rnre./brnc SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 245 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
h'or ondorple bells/is/all dcplhs if dVJerent(example-3 200'and 1@100') construction t0 the f011owing:
10.Static water level below top of casing: 40 Division of Water Resources,Information Processing Unit,
I/water 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 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
13a.Yield(gpm) 10 Method of test: I 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 22 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