GW1-2023-02922_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:
14:1ATERFZOIVES
Kolby Mitchell Sawyers
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft. I j
NC Well Contractor Certification Number "t50(I l`Elt"Gi1S 11ff'a.fprit(iiiti-�sdiw£Ifs rORxL11�Klr.If:$
FROM TO DIAMETER, THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 52 ft- 6.25 in. #21 PVC
Company Name
16 INrVER;GiCS1 1i7B 1G""ea€licrntatctosedrtp'"" a .<,.ri
Will Pieterse FROM b:DIAM VA 'THICKNESS MATERIAL
2.Well Construction Permit#: rt. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): ��17 SGREEN >A� am,?'k 'x
Water Supply Well: FROM I TO ➢IANTETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑MunicipallPublic tt. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) �� "_ � �
FROM TO MATERIAL EMPLACF.MF.NT METHOD&.4MOUNT
❑irri ation 0 et. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. rt. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
injection Well:
❑Aquifer Recharge ❑Groundwater Remediation xY9 SANDIGRAEI P,ACK`.'if:a licntile say£ .:,F w
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EAIPLACEME.NT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control
xZUy'D1EiLfli�iG I:t�G°atfaeli�addifional:ffeels`rf:neeessd"'" '
❑Geothermal(Closed Loop) ❑Tracer FRO nI TO DESCRIPTION color,hardness,soAlrock tv a gmin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fl. 52 ft. OVER BURDEN
2-27-2023 52 rt• 325 ft GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location:
Will Pieterse ft. ft. A�
2923
Facility/Owner Name Facility ID#(if applicable) ft. ft.
357 Shiners Ridge Bryson City 28713 ft. ft.
Physical Address,City,and Zip h21 REMARK$; tF,.'<,
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 IaUlong is sufficient)
N W 2-28-2023
Signature of Cettifi ell Contractor 7 Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this form,I herebv certify that the wells)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Coaviruction 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 emir,fill out knuim well construction information and explain the nature of the
repair under#21 remarks section or on the back of thlc 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 ifnecessary.
For multiple b jec•tion 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 zy'dii rent(example-3 tit 00'and 2(a,1001 construction to the following:
10.Static water level below top of easing: 50 (ft.) Division of Water Resources,Information Processing Unit,
If ivaler level is above casing.use'•+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
It.Borehole diameter: 6.25 (in.) 24b.For Infection 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,dircctpush,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) 10 Method of test: RI G 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this forth within 30 days ofcompiction 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 RI sotuces Revised August 2013