GW1--07486_Well Construction - GW1_20231120

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: I '
Kolby Mitchel Sawyers AliaWATERIONE , %X
R'ellContmctorName FROM TO DESCRIPTION
ft. ft.
4471-A .
ft. ft.
NC Well Contractor Certification Number >S15::011'CCrttCASt11j( ("a Uhf:reasitl ills)` leeftiEtt°(tf?8p1ati¢) NOM
CLYDE SAWYERS&SON WELL&PUMP INC FROM TO DIAME%I'NR THICKNESS MATERAAI.
+1 ft• 92 ft 6.25 , 1O #188 Steel
Company Name t)R r<c x
JMQ-303WeiNlvEttteMiNcts1Wer aithaiiiltfclo iii tool 1.; g
2.Well Construction Permit#: FROM TO . DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. • in.
3.Well Use(check well use): ft. ft. in.
iVSCRECN4 • «R a te'
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
III Geothermal(Heating/Cooling Supply) DI Residential Water Supply(single) ft. ' ft. in.
*iTndustrial/Commercial ()Residential Water Supply(shared)
,18i GROU;r 1T.010 '."" sue ` .
lirrigation FROM TO MA'TERI.A1. EhI PLACEM ENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• Bentonite Pumped
'Monitoring ()Recovery ft. ft. Cap Top with Bentomite chips
Injection Well:
ft. ft.
!Aquifer Recharge ®Groundwater Remediation SI SANICRAV LPACH^(lEapplli ]]) .? f-s
II Aquifer Storage and Recovery ®Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
!Aquifer Test 0Stomiwater Drainage ft. ft.
Experimental Technology (3Subsidence Control ft. ft.
)N!Geothermal(ClosedLoop) ®Traced(1)D1uL1;INGTOVattleh"additional:shcefilifaecessa°jj ' - "
FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
jA[Geothermal(Heating/Cooling Return) c3 Other(explain under#21 Remarks)
0 ft. 92 ft. OVER BURDEN
4.Date Well(s)Completed: 11-3-2023 Well ID# 92 ft. 185 rt.
GRANITE
ft. ft.
5a.Well Location: ''
Andrea Wilson ft. ft.
Facility/Owner Name Facility lD#(if applicable) ft. ft.
73 Mountain Haven Road Waynesville, NC 28786 ft. ft. NOV 9 II ZUZ3
Physical Address,City,and Zip ft. ft {1 s i ,
Haywood 7694-72-3839 4,2t 1tEivIAR+s . n '° , ,
County Parcel identification No.(PiN) this well was self certifird1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one lat/long is sufficient) 22.Certification: •
N N' 11-6-2023
6.Is(are)the well(s) Permanent or DTempurary Sigma e of er edlh ontrador Date
iX
By,signing di brin,I hereby cerift'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or EtNo with 15,4 NCAC 02C.010t)or 15A NCAC(12C.0200 Well Construction Standards and that a
If this is a repair..fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#2I 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:1 SUBMITTAL INSTRUCTIONS; •
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi(Prent(example-3@,200'and 21100') 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 Iniection Wells: In addition to sending the form to the address in 24a
ROTARY above,also submit one copy of tliis 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) 10 Method of test: RIG 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit;one 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.
i
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 2-22-2016