GW1-2021-00201_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
Derrick Heath Sawyers FROM ER ZONES
FROM TO DESCRIPTION
Well Contractor Name
rt. ft.
2436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)ORIN LER(if a 6cable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 128 ft 6.25 #21 1 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed400' r
SAS134W 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): 17;SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal Heating/Cooling Supply) ElResidential Water Supply ft. ft. in.
( t PP Y) PP Y
18.
❑industrial/Commercial ❑Residential Water Supply(shared) FRJ1 GROUT IA
O TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrrigation 0 ft. 20 ft- Bento6ite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licablc
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. tt.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 28 ft. OVER BURDEN
9-29-2021 28 ft• 205 ft. GRANITE
4.Date Well(s)Completed: Well 1D#
ft. ft.
5a.Well Location:
SABRINA SITTON _
ft. tt.
Facility/Owner Name Facility ID#(ifapplicablc) ft. ft. 3 9 y
QUALLA WOODS LOT 38 WAYNESVILLE, NC 28786 /
ft. rt.
Physical Address,City,and Zip 21.REMARKS,
HAYWOOD 8618-05-8611
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one tat/long is sufficient)
11-24-2021
N W
Signature RCerlified Well Ccnlracto Dale
6.is(are)the well(s): ❑�Permanent or ❑Temporary Br signing this form,I hereby certy[ 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 gjthis record has been provided to the well owner.
If 1hi.s is a repair.till out known well construction injorntalion and explain the nature of the
repair raider#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 supptr wells ONLY with the saute construction,you can
submit one(brin. SUBMITTAL 1NSTUCTIONS
9.Total well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple trells list all depths r/di&rent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:
30 Division of Water Res.) ources,Information Processing Unit,
ft
Il water level is abode (
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 forth 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(gym)
10 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13h.Disinfection type: PILLS 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