GW1-2023-00622_Well Construction - GW1_20230105

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.Kolby Mitchell Sawyers FROM ATERZ ONES- DESCRIPTION
Well Contractor Name
4471-A
NC Well Contractor Certification Number 15.OUTER CASING(tor multi-casedlwells) LINER>(if a Geable)
FROM TO DIAMETER I THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 152 it• 6.25 f 11O #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)'
DGS-012W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt. in.
List all applicable hell permits(i.e.Coma)•,State,Variance,b jection,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) El Residential Water SuPP1Y(single) ft. ft. in.
❑lltdttstrial/Commercial ❑Residential Water Supply(shared) 18.GROUTFROM I TO MATERIAL: EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft. 20 If- BentoOte Pumped
Non-Water Supply Well:
tt. tt.
❑Monitoring ❑Recovery
Injection Well: ft. tt.
[]Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK if a licablc
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20 DRILLING LOG(attach additional sheets if necessar
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soi0rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) 0 ft' 52 ft. OVER BURDEN
9-27-2022 52 ft- 225 ff- GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location:
Roy Ross
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
255 Eliza Cove Waynesville, NC 28785 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Haywood 8609-64-3129
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if'well field,one IaUlong is sufficient)
10-5-2022
&.eof Celifi �raclor Date
6.is(are)the well(s): ❑✓Permanent or ❑Temporary By signing this form,I hereby certify that the nvell(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 01C.0200 Well Con tton 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. i
/l this is a repair.Jill out known well construction information and explain the nature of the
`''�•, a
repair under#21 remarks section or on the back oJ'this form. 23.Site diagram or additional well details: � h j_ +� •�
You may use the back of this page to provide additional ite details or welt•L-.'
8.Number of wells constructed: construction details. You may also'attach additional pages I e4rLIF .2023
For muhiple h jection or non-water supply wells ONLY with the saute construction.You can `r,L;!':e.i
submit oneJnrat. SUBMITTAL INSTUCTIONS �,� rifts
r•trsr .1..�:i. ll
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days o'CcOillilr?�A)of t�eln�
For multiple wells list all depths f)"diJjerent(example-3 200'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,
hFivater level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection 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
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13a.Yield(gpm) 20 Method oftest• RIG 24c.For Water Supply&Injection;Welis:
Also submit one copy of this form within 30 days of completion of
136.Disinfection type: PILLS Amount: 20 well construction to the county Health department of the county where
constructed, iI
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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