GW1-2023-02921_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 44
FROM TO DESCRIPTION
Well Contractor Name
4471-A ft.
NC Well Contractor Certification Number el fp'r.fiufi91as¢dZRetls dRx:4tNER"if.8``##ealiten?a 'n
FROM TO I DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 160 fir- 16.25 i" #21 PVC
Company Name M6 1KNRE CN811NG.ORcTUR)Na %e'04h JfiAl!:closedr ,...
Yonni Martinez Gonzales FROM TO DIAMETKR 'THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Yar•iance,Injection,etc.) Ct. ft. in.
3.Well Use(check Well use):
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public tt. tt. in.
❑Geothermal(Heating/Cooling Coolin Supply) ®Residential Water Supply «. ft. in,
� � g PP Y) PP Y(single)
❑IndustriaUCommercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD 8:AMOUNT
❑Itr; ation 0 fr. 20 ft- Bentonite Pumped
Non-Water Supply Well:
tt. fr. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 419;-SAN1)1GRAY?EL 1?AGKN 1':a"lictible ::. b •; ?
❑Aquifer Storage and Recovery El Salinity Barrier FROM TO NIATERML EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft fr.
❑Experimental Technology ❑Subsidence Control
lU?DRILLIIVG E'IG.CaFCach addttiotial sheets if necessary' w � H
❑Geothermal(Closed Loop) ❑Tracer FROM[ TO DESCRIPTION ealar,hardness,soiVrock tv a grain sae,etc.)
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) 0 fr' 60 ft OVER BURDEN
2-24-2023 60 fr• 145 fr• GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location: 1 -
Yonni Martinez Gonzales ft ft. �R
Facility/Owner Name Facility ID#(if applicable) ft. ft.
97 Dehart Cove Bryson City, NC 28713
« rt
Physical Address,City,and Zip -.
21:,REMARCCS `.
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 2-27-2023
Signature ofCcrtiflylVell Contractor OF Date
6.Is(are)the well(s): OPermanent or ❑Temporary f f
By signing si •this arm,1 herelry certify that the well(s)was were constructed in acrnrdanre
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: ❑Yes or ©No copy of this record has been provided to the well ottncr.
If this is a repair,fill out known well construction information and explain the nature of tyre
repair under#21 remarks section or on the back oj'this•form. 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 ityec•tion or non-water supply wells ONLY with the same construction,),on can
submit one farm. ,1 SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 145 (ft.) 24a. For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths if dff ferent(example-3 dr 00'and 2(a1001 construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
Ij'nmler 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: constnuction 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 Centi r,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test RIG 24c.For Water Supply&Injectio I Wells:
PILLS C Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 2J well construction to the county health department of the county where
constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013