GW1-2023-02920_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 ;.14. ra I zti �� � . ' m" : ,
FROM TO DESCRrP,TTON
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number '.t' ixF,l t-ASI.IGr.foe uHia a U16,OlI-t INRI 1teat ,
FROM TO DIAMETERi TRfCKNFSS NrATF.Rt.AL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 115 rt• 6.25 #21 PVC
Company Name 16 INIVEt2 .,( O[tT,t3i33/4 C4f) rutal? il Ifl '" .
HI olito Martinez FROM '1'O DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: p ft ft. in
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): t7eSCREE.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single)
ft. ft. to
❑IndustriaUCommercial ❑Residential Water Supply(shared) `
FRO:\I TO MATEWAL� EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 et• 20 ft- Bentonite Pumped
Non-Water Supply Well:
rt. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: ft. rt.
❑Aquifer Recharge ❑Groundwater Remediation5i1NFlc; ., ]'AGK)C 'f.-N ��.
FROM I TO MATERIAL J EMPLACEMENT METHOD
❑Aquifer Storage and Recovery El Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
fr. fr.
El Experimental Technology ❑Subsidence Control
01.iRIC1L1Lsl '1 t.1(Ei.altarvli'addittiiitiil'shee�r'
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTTON Color,hardness,soiVrock ri e.j rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fr• 115 ft. OVER BURDEN
2-23-2023 115 fr• 385 ft- GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
Sa.Well Location: c '
Hipolito Martinez
rt. ft. F, �
Facility/Owner Name Facility 1D#(ifapplicable) ft. ft. J
294 DEHART COVE RD BRYSON CITY, NC 28713
ft. b
Physical Address,City,and Zip
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)
2-24-2023
Signature of`CWt:ihVWel1 Contractor F Date
6.is(are)the well(s): 2Permanent or ❑Temporary By signing this form,I herehv cer4fy that the well(s)ryas(were)constructed in accordance
with 15A NCAC 02C.0100 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 of this record has been provided to the well owner.
If this is a repair,Jill out knoi»n Hell cottstmctioit i7i rmation and explain the nature of the
repair tinder 921 remark,section or on the back oJ'thisJorm. 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: 1 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. p G 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 dl 2 00'and 2(S100') construction to the following:
10.Static seater level below top of casing: 80 (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 Iniection 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)4 Method of test: RIG 24c.For Water Supply&Injection Wells:
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.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013