GW1--06076_Well Construction - GW1_20230921

Igl:OFFTORSI
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Sawyers ,a4::w ArER oNE _,., t:,: Ni', __u ,., . m �
Well Contractor Name FROM TO DESCRIPTION
4471-A ft. ft.
ft. ft. I '
NC Well Contractor Certification Number
WC.OlITI`ER:Crtia+lgaG tfbi miitti cvbd`s{arts)©KLINERIif ap licabl6W A..z,t;tx
CLYDE SAWYERS&SON WELL&PUMP INC FROM TO DIAMETER THICKNESS MATERIAL
+1 ft• 165 ft• 6.25 i in. #21 PVC
Company Name I�/I/'� �tI�
l -308W :.01(.1.NNER;C"aI,SINGORTUBING:(geotheittiti:etiised loop)..:; �. ,. ,
Mi1
2.Well Construction Permit#: �'C FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. 1 in.
3.Well Use(check well use): ft. It. hi.
,,.17,ScREENi) ..... _ ,-, ^t"
Water Supply Well: Via. � .. ,
FROM TO DIAMETER:' SLOT SIZE THICKNESS MATERIAL
*Agricultural 0MunicipaUPublic ft. ft. in.
*i Geothermal(Heating/Cooling Supply) E3Residential Water Supply(single) ft. ft. in.
'Industrial/Commercial E3Residential Water Supply(shared) ; ROu r ,,-�8GLT � fi
;'Irrigation FROM TO MATERIAL• EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft• Bentonite' Pumped
*1 Monitoring 0Recovery ft. ft. l Cap Top with Bentomite chips
Injection Well:
ft. ft.
*Aquifer Recharge 0Groundwater Renscdiation ''
49:SAND%GRAVELFPACIC(if appllctb[c)V ._ *.,V. .ri<,€t.s. '?
"'Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
*Aquifer Test 0Stonnwater Drainage ft. ft. i'
Ill Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) E3Tracer 20:41.R.ILLING.LOG(attacfi oilditi6tist.'sheets if Ocess>iry `` ,R 4 , f'
*Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM ToDESCRIPTION(color,hardness,soil/reek type,grain size.etc.)
0 ft. 70 ft• uP:SCRI OVER BURDEN
4.Date Well(s)Completed:07/07/2023 Well ID# 70 ft• 165 ft• GRANITE
5a.Well Location: ft. ft.
Lisa Akers ft. ft. 4 r.; f,+-,r
Facility/Owner Name Facility ID#(if applicable)
ft. ft. i% 4.-0 ...is V 1..e'
15 Pacific Drive,Waynesville 28785 It. ft. SEP 2 1 2023
•
Physical Address,City,and Zip ft. ft.
Haywood 8750-24-1768 OL°REgtAB1.0,; „ . a 0:,'.�N G:*;tL J
County Parcel identitication 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 Temporary Signa c of Cc ed ontmctor ' Date
By,signing th Arm,I hereby certif•that the well(s)was(mere)cansn•ncted in accordance
7.is this a repair to an existing well: Yes or 0No with iSA NCAC 02C.0100 or 15A NCAC,02C.0200 Well Construction Standards and that a
IJ'this is a repair,Jill out known well construction infbrntatian turd explain the nature nJ7he copy ofthis record has keen 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 I GW-1 is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
i
9.Total well depth below land surface: 165 IN 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple we/Ls list all depths ifdifferent(example-3 rt 200'and 2@100) construction to the following:
10.Static water level below top of casing:20 (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 Injection Wells: in addition,to sending the form to the address in 24a
ROTARY above,also submit one copy of thislfoim within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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 submiqorie 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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016