GW1-2021-04680_Well Construction - GW1_20210517

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
14.WATER ZONES
X'
Kolby Sawyers FROM TO DESCRIPTION_
Well Contractor Name ft. ft.
4471-A ft.
�
NC Well Contractor Certification Number 1��'OUTER,CA
FROMT" 1 THICKNESS MATERIAL
I' .
CLYDE SAWYERS & SON WELL & PUMP INC +1 ". 1 1 16.25 in 1 , #21 1 PVC
A6.1NNERCASINGORT ING16otbermaUclosed4ocip),"'
Company Name
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#- 200526 in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. i in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS, MATERIAL
DAgricultural DMunicipal/Public ft. ft. in
OGeothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. ft. in
OIndustrial/Commercial OResidential Water Supply(shared) 18.GROUT ', -
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
DIrrigation 0ft. 20 ft- BentoNte Pumped
Non-Water Supply Well:
OMonitoring ORecovery
Injection Well: ft. fL
E]Aquifer Recharge 0 Groundwater Remediation
CAquifer Storage and Recovery OSalinity Barrier ft ft
FROM TO MATERIALI EMPLACEMENT METHOD
OAquifer Test OStormwater Drainage
DExperimental Technology OSubsidence Control
'yO'G11 attach-additional s
DGeotbermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grein size,etc)
OGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) 0 101 ft OVER BURDEN
02-19-2020 101 265 GRANITE
4.Date Well(s)Completed: -----well ID#
5a.Well Location:
Lanier C. Dickerson
Facility/Owner Name Facility ID#(if applicable) ft.
155 Bronco Dr., Bryson City
Physical Address,City,and Zip
2i—REMARKS'
Swain
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certific 'on:
(if well field,one lat/long is sufficient) r1J ) C 03-05-2021
N W lcew
ignature of efri Well Contract Date
tP 1�
6.Is(are)the well(s): 2 Permanent or ElTemporary By signing this form,I hereby certifv 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: OYes or END copy ofthis record has been provided to the well owner.
If this 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 or non-water supply wells ONLY with the same construction,You can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion,of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Res�ources,Information Processing Unit,
lfwater 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
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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service tenter,Raleigh,NC 27699-1636
13a.Yield(gpm)4 Method of test: RIG 24c.For Water Supply&Injection Wells
Also submit one copy of this fdrm within 30 days of completion of
13b.Disinfection type. PILLS Amount: 15 well construction to the county }ealth department of the county where
constructed. I
Form GW-I North Carolina Department of Environment and Natural Resources—Division ofWater'Resources Revised August 2013