GW1--06075_Well Construction - GW1_20230921

Prin for m x 1
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Sawyers 14:WATER :ONES .. .. _•..a. t - ., r,„,:
FROM _ TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
ft. ft.
NC Well Contractor Certification Number ./15.'O[[TER'CA,StNG(fi r it nttl-catedtWellS)ORLtNER`(ifirip tieahle),^=: s ,.,..'..'',7
CLYDE SAWYERS&SON WELL& PUMP INC FROM TO DIAMETER THICKNESS MATERIAL
+1 it' 75 ft' 6.25 I in- #21 PVC
Company Name
J MQ-311 W 16alkII,rER CASINOOR TUDING( -Mliermaretiiiet iaap) ,x_ _
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UKC.County.State.Variance.etc.) ft. ft. hi.
3.Well Use(check well use): ft. ft. ; in.
Water Supply Well: ',17:SCREEN, �,.. rt IAi., ' r• ,
FROM TO DIAMETER ER I SLOT SIZE THICKNESS MATERIAL
•Agricultural 0MunicipaUPublic ft. ft. in.'
ll Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ff. in.; •
It Industrial/Commercial JResidential Water Supply(shared) ,18;GRour k, ,.„. ..
nh
•1Irrigation FROM TO MATERIAL . EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• Bentonite; Pumped
*1 Monitoring 0 Recovery ft. ft. • Cap Top with Bentomite chips
Injection Well:
ft. ' ft.
0IAquifcr Recharge 0Groundwater Rcmcdiation I
f.C.I.9.,SAKDIGRAVECPACKtif applicable) *',; 1
liAquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
it Aquifer Test DStormwater Drainage ft. ft.
l'Experi mental Technology OSubsidenceControl ft. ft.
Geothermal(Closed Loop) OTracer 2(1'f.DRILLING WO(attncli additional i3fieetsafneecssary) N) ., „a:i ,. •,, F=
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rocktype,grain size,etc.)ig
0 ft- 75 ft• OVER BURDEN
4.Date Well(s)Completed:07/10/2023 Well ID# 75 ft. 305 ft. GRANITE'
5a.Well Location: I't, It, i,4;::e $.^ h„>:
Thomas Kiplen Ray R. ' ft.
. ..4-.',-,L•i �ii L.
Facility/Owner Name Facility ID# ' f r(if applicable) ft. ft. S C p 1 1 2023
I _
Latern Dr, Clyde, 28721 ft. ft.
ft- ft, inforitr. 1 fl Pr, :: .v tirtii
Physical Address,City,and Zip (NAT:11S.
Haywood 8657-17-5685 zfi-RSA 1Rxs a ,u. . _ ;i:: .r w.: .,"-tr ,.-•
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W 07/18/2023
6.Is(are)the well(s)JPermanent or JTemporary Sigma a ofCe ed onttacror °" Date
By.signing th Ann,1 hereby certify that:I/te well(,)was(mere)consn•acted in acc•a•dahce
7.Is this a repair to an existing well: FIYes or EiNo with 15.4 NCAC 02C'.0100 or 1SANCAC 02C.0200!Veil Construction Standards and that a
If this is tt repair,fill out known well construction it formation and explain the nature of the copy of this record has been provided to the,well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS i
i
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 a 200'and 2 at 100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,,Information Processing Unit,
If water level is above casing,use'•+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection Wells: In additi n to sending the form to the address in 24a
ROTARY above,also submit one copy of this fort 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 2 769 9-1 63 6
13a.Yield(gpm) 4 Method of test: RIG 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit ne copy of this form within 30 days of
13b.Disinfection type: PILLS Amount: 20 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016