GW1--03541_Well Construction - GW1_20230519

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 TElz7.(LNIsS DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NCWe1lCovirnctorCertificationNumber f5,0U1>JRCAStNG fo'r:mnthcasedtivells.OR-LINEf2 tfs ltcsbie'i
FROM TO DTAMFTF.R TATCKNFSIS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 42 ft• 16.25 1 1 in- 1 #21 1 PVC'
Company Name 16ANNU C'ASING,ORT RING 4pthernta[;ctesed-Ipti"
MCM-340W FROM DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: rt ft. in.
List all applicable vviUpennits(i.e.County,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 'IT SCREEN,REEN _...,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft.❑Agricultural ❑Municipal/Public in.
❑Geothermal (Heating/Cooling Supply) 7Residential Water Supply(sin(single)
❑IndustriaUCommercial ❑Residential Water Supply(shared) FRonROBT.._:.:.
TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑l1Ti ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
t'c. rt. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater RcmediationTO FRO
M
❑Aquifer Storage and Recovery El Salinity Barrier MATEruAL EMPLACEMENT hIETHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
NG1OG'a'iwhaddi❑Geothermal(Closed Loop) ❑Tracer TO DESCRIPTION eolDr,hardness,soil/rmk tv a rein size,etc.)
❑Geothermal Heatin Coolin Return ❑Other(ex lain under#21 Remarks) 2 rt OVER BURDEN
3-6-2023 765 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft.
5a.W'ell Location: ft.
Jeremy Merrell ft. ft. i V" • �'�
Facility/Owner Name Facility ID#(ifapplicable)
ft, ft.
Grasty Rd, Clyde ft. MAY
Physical Address,City,and Zip ......
Haywood 8646-16-8705 ,�
County Patel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one ladlong is sufficient)
N W Q4-27-2023.
Signature ofCcitifliMell Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this firm,i herehv certify that the well(s)was(were)constructed in accordance
ivith 1 SA NCAC 02C.0100 nr 1 SA NCAC 02C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy of this record has been provided to the well owner.
If this is a repair,frll out knuim well construction information and explain the nature of the
repair under#21 remarla•section or on the back ofthis form. 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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the sumo construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface• 765 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi)f rent(example-3@i200'and 2(4,100D construction to the following:
10.Static water level below top of casing: 80 (ft) Division of Water Resources,Information Processing Unit,
If aaater 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 oi'Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service!Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 8 Method of test: RIG
24c.For Water Supply&Injection,Wells:
Also submit one copy of this form within 30 daysofcompletion of
13b.Disinfection type: PILLS Amount: 35 well construction to the county health department of the county where
constructed.
i
Form OW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013