GW1-2023-01979_Well Construction - GW1_20230227

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
4
_14.'�,,�VATERZONES
DERRICK SCOTT LEDFORD FROM TO DESCRIPTION
Well Contractor Name
4022-A ft. ft. I
NC Well Contractor Certification Number M',OUTERCASING f, I DINER. ap UIWcAg6rW,cI S)0!F_ licable
C"
FROM TO DIAMETER TIT E9 MATERIAL
CLYDE SAWYERS AND SON WELL DRILLING +1 ft- 161 ft 6.25 i #21 1 PVC
Company Name t6:INNER CASING-OR T BING
FROM To DIAMETER THICKNESS MATERIAL
2.Well Construction Permit 4: J S E—11 OW ft. ft. in.
List all applicable ivellpernzits(i.e.County,State, Variance,Injection.etc.) ft. in.
3.Well Use(check well use):
17:'S C ft CE K
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ElMunicipal/Public
DGeothermal(Heating/Cooling Supply) ©Residential Water Supply(single)
El In du stri al/Commerc ial 0 Residential Water Supply(shared) '18�GRQIJY­'
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
DIrrigation 0 ft. 20 • BENTbNITE PUMPED
Non-Water Supply Well:
ElMonitoring 0 Recovery
Injection Well:
[]Aquifer Recharge DGroundwater Reiriediation .J$QSAND/GHAVEL,PACK(If fopfla6re�_'
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery DSalinity Barrier
ft. ft.
ElAquifer Test DStonnwater Drainage
DExperimental Technology EISLibsidence Control
20.DRILLING LOG(attach additi6nal'sheets
EiGeothermal(Closed Loop) ElTracer FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
ElGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 05-04-2014 Well ID# 0 61 ft. OVER BURDEN
5a.Well Location: 61 ft' 565 ft.ft 0 Q,A,t4 I Tf,
GREGORY WISHART rt. .
Facility/Owner Name Facility ID#(if applicable)
=
WISHART WAY CLYDE , NC ft. ft.
Physical Address,City,and Zip 2V REAIAR'Kg"�,'�"
HAYWOOD 8627521229
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.C tification:
(if well field,one lat/long is sufficient)
0
82.94963 N35.531406 W 06-30-2020
ig ziature of;CertifzledWell Contractor, Date
'
6.Is(are)the well(s): RPermanent or OTemporary BY signing this form, I hereby certify ,,at the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: OYes or KNo copy ql'this record has been provided to the well owner.
If this is a repairfill out known well construction hilbrination and explain the nature of the i
repair under 421 reniarks section or on the back of this.1brin. 23.Site diagram or additional well details:
1 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 als6 attach additional pages if necessary.
For multiple injection at,non-water suppti,wells ONLY ivith the same construction,you can 11
submit oneform. SUBMITTAL-INSTUCTIONS 1
9.Total well depth below land surface: 565 ( .) 24a. For All Wells: Submit th I
ft is form within 30 days of completion of well
For multiple wells list all depths if different(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: (ft.) I
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 246. For Iniection Wells ONLY} In addition to sending the form to the address i.n
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ROTARY AIR construction to the following: t
(i.e.auger,rotary,cable,direct push,etc.) - I
Division of Water Resources,
Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cepter,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
PILLS well construction to the county ilea'th department of the county where
13b.Disinfection type: Amount- 25 ty I I
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013