GW1--04523_Well Construction - GW1_20230713

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'.0AVATEIVZONR.Sr� v.t:1 M`;rItefa� 3 s.MMIt
FROM , TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number 15.OtITERi ASitYG(formdltleas¢dtt'Clls).OIt.U1NEft`(ifa�p iteabte)` � ,..n;._..
FROM TO DIAMETER THICKNESS MATERIAL.
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft' 42 fit• 6.25 i #21 Pvc
Company Name
1eit9IVER ASIN QR+TUftiN (geotl)ermil closed-ieop)W,- ' ',...;ar,r,40
JMQ-277W HROaI To DIAMNIEN THICKNESS alA'1'H:R141.
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): ,a17:SfiREEiY ;., 'xa u 4 -- o - ~+ `
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS , MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Publie .
❑Geothermal(Heating/Cooling Supply) EEIResidential Water Supply(single)
ft. ft. in.
� � g PPY) PPY( g
❑IndustriallCommercial ❑Residential Water Supply(shared) -SSR^GROUTS% u„ F 4, , '.— ft
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hrigation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: It. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19 SANIRORi1•' EL PACK tiCajlp(tctitilel . Vati''A
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control ,,,
120 1{11XINGT.{lari`il"iaiTtiddiftlii tsheetslif=uec�ssarv) i
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 42 ft. OVER BURDEN
5-24-2023 42 ft. 305 ft. GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location: ft. ft. . :.'"...4..•••''L.-a r, k f'
Rodney&Stephanie Horcoff ft. ft.
Facility/Owner Name Facility ID#(if applicable) JUL1 2023
ft. ft.
150 Lost Trail Lake Lure NC 28746 ilh....••.1,..i1 P.,-.....,,,,::-,3 ia,
ft. ft.
l INO Yli I.)*Z21
Physical Address,City,and Zip Ii21 ltt MARKSII- "`.�' "s.,. _ `? ' e ' tfa
Haywood 8618-57-7442 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 5-25-2023
Signature of Certifi ell Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby certify that the well(s) was(were)constructed in accordance
with 15A NCAC 02C.0100 nr J5A 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.fill out known well construction information and explain the nature of the
repair under#ll remark''section or on the back of this_/bra. 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: 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. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 305 (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 00'and 2(4)100') construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
H.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
(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) 7 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: 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 WateriResources Revised August 2013
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