GW1-2022-07732_Well Construction - GW1_20220819

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Derrick Heath Sawyers FRO ATERZONES DESCRIPTION
Well Contractor Name
2436-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased ivells)OR LINER iIa licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 I'L 4s ft 6.25 In #21 PVC
Company Name Q 16.INNER CASING OR TUBING(geothermal closeddoo
SAS-202W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. Ia•
List all applicable well permits(i.e.Count),,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.❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. It. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 f" 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
El Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheetsif necessar
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 8 ft. OVER BURDEN
7-5-2022 48 IL• 605 It- GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
John M Tench
Facility/Owner Name Facility ID#(if applicable) ft. ft P(I r
Debbie Loop Bella Matagna Sub jot 9 Waynesville, NC 28786 J
rt. e.
ra
Ilia
Physical Address,City,and Zip 21.REMARKS vti
Haywood 8636-95-7271 �'c.
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 Vy S 7-8-2022
Signature of Certified Well Contracto Date
6.Is(are)the well(s): R Permanent or ❑Temporary Br signing this form,1 hereby certily 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 ONO copy ojlhis record has been provided to the well owner.
ll this is a repair,/ill out known well construction information and erplain the nature of the
repair under#21 remarks section or on the back o/'dus 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.
Fur multiple in/ectum ur non-Hater supply wells ONLY with the same construction,you can
submit onefa•m. 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 wells list all depths i/'diljerent(example-3 a,200'and 2@100') construction to the following:
10.Static water level below top of casing: 80 Division of Water Resources,Information Processing Unit,
i1 it-rner level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b. For Injection Wells ONLY:i'In addition to sending the form to the address in
ROTARY 24a above, also submit a copy of Pthis 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 IDjection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gym) Method of
6 test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this for within 30 days of completion of
PILLS
13b.Disinfection type: Amount: 35 well construction to the county he m alth department of the county where
constructed. E
Form 6W-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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