GW1--03612_Well Construction - GW1_20230522

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Derrick Heath Sawyers � �
FROM TO DESCRiP,TTON ,
Well Contractor Name ft. ft.
2436-A ft.
NC Well Contractor Certification Number $;01J11 t ASIN', 41000k 011t13 't lie
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 27 ft- 6 1/8 in. #188 Steel
Company Name
lwlyi~ttx ° .G,ol eusli� se lirermal<stosed-rov'' ��
WP23-042 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County•,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): t7St
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in•
❑Geothermal(Heating/Cooling Supply) ©Residential Water Supply(single) ft. ft. in,
❑IndustriaUCommercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑ln; ation 0 et• 20 ft- Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery Cap Top with Bentonite Chips
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation 14fSMMml "UEVPx ii 3i"6ftenbl�
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
[]Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 2tt 1 L L j i a lr addfir
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock tv a rain size,etc.)
❑Geothermal(Heating/Cooling Return ❑Other(explain under#21 Remarks 0 ft. 27 ft. OVER BURDEN
5-11-2023 27 rt 405 ft GRANITE
4.Date Well(s)Completed: Well ID#
Sa.Well Location: ft. ft. �^� �•
Thomas & Sheri Blythe ft. ft. MAY 2 2 2023
Facility/Owner Name Facility ID#(if applicable) ft. ft.
141 Bob Drive Pisgah Forest, NC 28768
v ,
Physical Address,City,and Zip
Transylvania 9508-99-5250-000 Well Was Self Cetified
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N `1 �Onik_svdwA 5-17-2023
Signature of ertified Well Contracto Date
6.is(are)the well(s): 2Permanent or ❑Temporary By signing this fiorm,1 herehv certify that the well(s)was(were)constructed in accordance
ivith 1 SA 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 oxner.
If this is a repair,fill out knunn well construction information and explain the nature of the
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
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 same construction,you can
.submit one form. ,t SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple ivells list all dept&ifdj#erent(example-3 dl 00'aml 2(al00) construction to the following:
10.Static water level below top of casing: 60 (ft) Division of Water Resources,Information Processing Unit,
If xuter 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'ithis 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) 3 Method of test: RIG
24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Arnount• 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