GW1-2023-01978_Well Construction - GW1_20230227

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I44
1.Well Contractor Information: I'
Kolby Mitchell Sawyers z::�ar> 5::::z
FROM TO DESCRIPTION
Well Contractor Name
4471-A ft. ft.
NC Well Contractor Certification Number %"j�%-0u,-LR3CdStlt: tor'multi>casetl3tiei[s':Olt?f liVElt''fa'licali[e=:'Azt>`:< :-:-:- z=:
FROM TO D)AMRTF.R THmCKNF,SS r MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 126 ft- 6.25 j in- #21 1 PVC
Company Name E1Ni±Il IZ3GAS!!!/G;OR CUBa31G `kOftJli gtaTtoSett7Qu 0'"��=i' :- E 's:,x-�':
SAS-181 W FROM 1'O DIAMF,,rER THICKNESS MATERIAL
2.Well Construction Permit#:
ft. ft. in.
List all applicable well pennits(i.e.County,State,Variance,Injection,e(c.) ft ft. in.
3.Well Use check well use): -_
Water Supply Well: FROM TO.._ DIAMETERS <.SLOT SIZE THICKNESS I MATERIAL
ft.
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. tn•
❑Industrial/Commercial ❑Residential Water Supply(shared) x&GRO[7T
FROM TO MATERIAL EMPLACRMF.NT METHOD&AMOUNT
❑li•ri ation 0 ft. 20 n• Bentonite Pumped
Non-Water Supply Well:
ft. ft. ,
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑GrouudwaterRemediation =19S.itNIT/GRA`:3?EIF1�K-'it`"a'""
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology El Subsidence Control
2U D111111 Qo C1G'aifaetttaii5l s'><f i"ifaieeessa'" °...'�a
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 6 ft. OVER BURDEN
09-28-2022 26 fr• 245 fr• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft. S
Melanie and Phillip Lamb
Facility/Owner Name Facility ID#(if applicable) FED 1r. r 3
ft. ft.
11 Ladyslipper Lane, Waynesville ft. ft. If1iC.in:6;*t3 �f . Jr
�= g Urii
Physical Address,City,and Zip ,::: Y v:;r;_ y .-« :a
Haywood 7684-6-1-6776
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N W 01/12/2023
Signature ofCcitifilywell Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 herehv certify 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 ©No copy of this record lots been provided touhe well oxmer:
If this is a repair,fill out known well construction information and explain the nature of the
repair under 921 remarlo section or on the back of this jornt. 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 due same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface• 245 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ij'dii ferent(example-3(u200'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,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
r
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 ofi 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 m 10 Method of test- RIG 24c.For Water Supply&Injection Wells:
(gp ) Also submit one copy of this form;within 30 days of completion of
13b.Disinfection type: PILLS Amount: 35 well construction to the county health department of the county where
constructed.
Fonx GW-1 North Carolina Department of Environment and Natural Resources—Division of water Resources Revised August 2013
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