GW1-2022-09526_Well Construction - GW1_20221017

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers FROM AT R'7TO
DESCRIPTION E
Well Contractor Name ft. ft.
4471-A ft. ft. I'
NC Well Contractor Certification Number f5:'OUTF[tCASING fdfm"Idcasedwetls:Ott;LINER ifs licable
FROM TO DiAMF,TF.R THICKNESS MATFRiAi.
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 176 It- 16.25 i" 1 #21 1 PVC
Company Name IbrINNERCA$ING'ORTUBIK eothernint"stosedlAv` -
MCM-352W FROM DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. '"
List all applicable well permits(i.e.County,State,Yariance,Injection,etc.) ft ft• in.
3.Well Use(check well use): J2SGREEN ,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Murlicipal/Public
in.
❑Geothermal (Heating/Cooling Supply) ElResidential Water Supply(sin(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) IB:=GROUT
FROM TO MATERIAL RMPLACF,MFNT METHOD&AMOUNT
❑IrTi ation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
tt. tt.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recbarge ❑Groundwater Remediation 29iSAND/CRAYEI PACK d.a" cable ..__a: s._..:�
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. ft.To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stomtwater Drainage
ft. ft.
El Experimental Technology ❑Subsidence Control
3tl>LFRI LINC:=GOG>a[lash:addttiuii5fsbeet'sif-necessa"'<» .. .... .`,s....:.. .....::
❑Geothermal(Closed Loop) ❑Tracer FRODI TO DESCRIPTION color,hardness,soilIrmkty a grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) 0 ft- 76 ft. OVER BURDEN
9-30-2022 76 ft- 385 ft. GRANITE
4.Date Well(s)Completed: Well ID#
rt. rt.
5a.Well Location: ft. ft.
Linda and Edward Roberson
1- \
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
684 Scruggs Circle ft. 7 2022
Physical Address,City,and Zip e
ZI:REMARKS'c•. ...
Haywood 8668-60-5494
County Parcel Identification No.(PIN) y "�
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
(if well field,one lat/long is sufficient)
N W 10/05/2022
Signature of CcitiflyWell Contractor Date
6.is(are)the we11(s): 17Permanent or ❑Temporary By signing this form,1 herehy certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0/00 or 1 sA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy ofthis record has been provided to the well owner.
If this is a repair,fill out knuna well construction information and explain the nature of the
repair under 921 remarks section or an the back ofthis 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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the.came construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 385 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(d200'and 2(q,100) construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
lfwater 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.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(gpm) Method of test:
20 RIG 24c.For Water Supply&Injection;Wells:
PILLS Also submit one copy of this form' within 30 days of completion of
13b.Disinfection type: Amount 35 well construction to the county Health department of the county where
constructed ` I
Forat GW-I North Carolina Department of Envimmueut and Natural Resources—Division of Water Resources Revised August 2013