GW1-2022-03011_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
Kolby Mitchell Sawyers F4.WATERZON: '
FROM TO DESCRJ PTION
Well Contractor Name ft. ft.
4471-A rt. it•
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER{if;a" ti ble)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 79 tt. 6.25 i #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop),
WP20-048 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt. in.
List till applicable well permits(i.e.Couny,State. Variance,hilection,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) EDResidential Water SuPP1Y(single) ft. ft. in,
❑)nclustrial/Commercial ❑Residential Water Supply(shared) 18:GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri aeon 0 ft. 20 rt• Bentonite Pumped
Non-Water Supply Well:
rt. rt.
[]Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stotmwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20 DRILLING LOG(attach additional sheets if necessar
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)J 0 rt' 79 ft' OVER BURDEN
2-9-2022 79 ft 605 ft GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
MORGAN WHITMIRE
Facility/Owner Name Facility ID#(ifapplicablc) f[. ft.
481 FOX DEN HILL BREVARD, NC 28712 ft. e. FEB 2 8 202?
Phvsical Address,City,and Zip 21.REMARKS
TRANSYLVAN IA 8563-89-2116-001
-
Countv Parcel Identification No.(PIN) `.w
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one]at/long is sufficient)
N W Cxt 02/16-2022
Signature ol'CertifilvWell Contractor f Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form, 1 hereby certyj,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 IDNo copy gf1his record has been provided it)the well owner.
I/1hi.s is a repair.fill out known well construction inlin-neation and explain the nature o/'the
repair wider#21 remarks section or on the back o/'this.jorm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
Fur nudtiple injection or non-water supply wells ONLY with the sate construction,you can
"uhlnit one 161.117. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 605 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple rrelh list all depths i/different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 120 (ft) Division of Water Resources,Information Processing Unit,
If water 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.auget,rotury,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) 3 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: 35 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 201 s