GW1-2022-07770_Well Construction - GW1_20220822

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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I.Well Contractor Information:
14.WATER ZONES
Kolby Mitchell Sawyers FROM TO DESCRIPTION
Well Contractor Name
4471-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wills)OR R LINE if a 'licable
FROM I TO I DIAMETER, THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 132 fl 6.25 '" #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER, THICKNESS MATERIAL
2.Well Construction Permit#:
2022-22658-9-11812 ft ft
List all applicable Nell permits(i.e.Couno,,State. Variance,Injection,etc.)
ft. Pt. 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
❑Geothennal Heatin Coolin.-Supply) EIResidential Water Supply ft• ft• in.
( � b PP Y) PP Y
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hTigation 0 ft' 20 ft. Bentonite 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
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type, rain size,etc.
❑Geothennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 32 tt OVER BURDEN
8-2_2022 32 ft 225 tt GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location:
Alvin Webster
Facility/Owner Name Facility ID#(if applicable) ft ft
1462 Greens Creek Road Sylva, NC 28779 ft. rt.
Physical Address,City,and Zip 21!REMARKS
Jackson 7569-31-0597
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification•
(ifwell field,one tat/long is sufficient)
8-10-2022
N W
Signature ofCertifilyWell Contractor .
6.Is(are)the well(s): 2Permanent or ❑Temporary tat,signing this form,1 hereby certify that the well
(sj w� }�obstcacri�n rice
with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Consuttction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy gfthis record has been provided to the well owner. n J I (' q 2n27
/(this is a repair,lilt o+d known well construction infirrmation and e-rplain the nature of the 1' �� d l.,
repair wider#21 remarks section or an the back ol'this.fornz 23.Site diagram or additional well details:
You may use the back of this page to provW#&A4W�3kINQKL "ell
8.Number of wells constructed: 1 construction details. You may alsoiattach additional pa§0WQIJ34DQry.
For out/tiple injection or non-[cater sllpp/r wells ONLY with the saute construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
l-nr multiple wells list all depths#'dilferent(example-.3@200'and 2@100') construction to the following:
20 Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing:
l/'1raler 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 ofl this 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 Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I3a.Yield(gpm) 30 Method of test: RIG 24c.For Water Supply&In.lectioln Wells:
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Also submit one copy of this form'within 30 days of completion of
13h.Disinfection type: PILLS Amount: 25 well construction to the county health department of the county where
constructed.
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Form G W-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013