GW1-2023-02919_Well Construction - GW1_20230420

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 TO DESCRIPTION
Well Contractor Name ft. ft. I
4471-A ft. ft.
NC Well Contractor Certification Number ft51TOOTEft ASitilatfor tiiitagirsidtiak rORVINE1'!.{If$�jf'p`)ot) �
FROM TO DIAMETER THICKNESS MATERIAL.
CLYDE SAWYERS & SON WELL & PUMP INC +1 it. 52 ft. 6.25 in. #21 Pvc
Company Name did.INNEft AS18t:. lR"C1.7B)J9fy';{Q6iliermal;ctosed-tpu) "a `''' e.. `
Will Pieterse FRO
2. THICKNESS atA'I'NHI.41,
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) CL ft. in.
3.Well Use(check well use): ,TIVSCREENW,WWW43VMVM,iiMIWASAV ' ' 5'„�
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. m '
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 41SiGrROUT• � ; ds.• � � •-, � .
FROM TO MATERIAL EMPLACEMENT METHOD&.AMOUNT
❑irrigation 0 ft. 20 ft• Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft. Cap Top with Bentonite Chips
injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation V19 SAND/GRAVELtPAGK`( ':ap`pticnlilels . V ' ` `•s `IN
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft ft.
❑Experimental Technology ❑Subsidence Control
tIeDRIIIINGECia atxacliadditio"nal`fiViti4146a146 - `E TO
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 52 ft• OVER BURDEN
2-27-2023 52 It. 325 ft• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft. 1:7: ..... --
5a.Well Location:
Will Pieterse ft. ft. APR 2
Facility/Owner Name Facility ID#(if applicable) ft. - ft. O 2023
357 Shiners Ridge Bryson City 28713 ft. ft. "-Physical Address,City,and Zip hJ ,�t;;;
r i}
21.:RENIARKSAU,.<=,.ZIS4M;MMna. , ,„ :,U
Swain Well Was Self Certified
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W 2-28-2023
Signature of Cettifi ell Contractor Date
6.is(are)the well(s): OPe)moment or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the well o)rne,
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this farm. 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 the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 325 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dim rent(example-i nil 00'and 24100') construction to the following:
10.Static water level below top of casing: 50 (ft.) Division of Water Resources,Information Processing Unit,
If water 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
I
13a.Yield(gpm) 1 0 Method of test: RIG 24c.For Water Supply sr Injectio I 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.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013