GW1-2022-07739_Well Construction - GW1_20220819

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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 RA'I-ER:7ANES..
Kolby Mitchell Sawyers FROM TO DESC.RIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number 15':f3t1TERCAStt+tG.for.ruttieasedweits 01t1I1V£Ct tfa Itcsble= y:
FROM TO DIAMETER; TTOCKNFSS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 fl• 56 ft 6.25 #21 PVC
t6'11v1V£RXA$f1VG,OR[#1B1NG kometnialstosed7oir sft
Company Name `E
MCM-319W FROM TO OIAMNIN:R I'RICKNFS Is1MATERIALMATERIAL2.Well Construction Permit#: ft• ft. in.
List all applicable svell permits(i.e.County,State,Variance,Injection,e(c.)
ft. tL in.
3.Well Use(check well use): t?s:5C12E)N �.� ...
Water Supply Well: FRODI TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. ft. in:
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) 911esidential Water Supply(sin(single) ft. ft. in.
❑IndustrialICommercial ❑Residential Water Supply(shared) _FROM� TO MATERIAL EMPLACEMENT METHOD&AMO rT?rl
❑hTi ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supplv Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediationi9S�SNDIDR�iLPAf=
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier tt [t
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20 1f1t1C t iGALIA6G.stttaeti addlifurtalsheets: itecessa. ==
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rmk type rain size,etc.
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remark 0 tt 56 ft OVER BURDEN
8-17-2022 56 ft 405 ft GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location:
Richard Hendricks4.
Facility/Owner Name Facility ID#(ifapplicable) , t s
ft. ft.
Peach Bloom Dr. ft. ft. , 1 9 202?
Physical Address,City,and Zip 21,itEMARKS.
Haywood 8657-55-8776
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 W 08/18/2022
Signature of'CertififWth Contractor; I Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 herehv certify that the wells)was(were)constructed in aceordanre
with 1 SA NCAC 02C.0100 or 1 SA NCACA2C.0300 Well Comtruc•tlon Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No copy of this record has been provided to the well owner.
lfthis is a repair,fill out knunn well cunstructiun information and explain the nature of the
repair under#21 remarks section or on the back of this farm. 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: 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 wee form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:40 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depthv ifdt/ferent(example-3(aj200'and 2(a.100) construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
ff 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: constriction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resource`s,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 I ealth department of the county where
constructed.
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Forts GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013