GW1--07723_Well Construction - GW1_20231122

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: j'
1.Well Contractor Information:
Kolby Mitchel Sawyers
FROM TO DESCRIPTION
Well Contractor Name ft ft.
4471-A
ft. ft.
O
NC Well Contractor Certification Number f5.100T. 'N gitCASlkedeinu[t 1 ciitil ellsjin 1NGRttFap Icalile) ,.. Mird
CLYDE SAWYERS&SON WELL& PUMP INC FROM TO DIAMETER THICKNESS M.ATERIAI.
+1 ft. 92 ft• 6.25 ,in. #21 PVC
Company Name ,. , _,
2022-23858-912718 la iNr Ele0ASI ORVII Ntre tfier ol. soy=to .
2.Well Construction Permit#: FROM , TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. I in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: WI?SCRE+IPI . , .:a:. ' '
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
*Agricultural 0Municipal/Public ft. ft. in.
*Geothermal(Heating/Cooling Supply) E3 Residential Water Supply(single) ft. ft. in.
I Industrial/Commercial QResidential Water Supply(shared) V8 GFt()UT' q.:'1 . i$ . . 44„
'irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. Bentonite : Pumped
ill IMonitoring DRecovery ft. ft. Cap Top with Bentomitechips
Injection Well:
ft. ft. ,
I Aquifer Recharge ®Groundwater Remediation
i I9'1Sid"ND/OR 3 L,PAGICs0110 I.46f} " '.-
*Aquifer Storage and Recovery OSalinity Barrier FROM TO . MATERIAL EMPLACEMENT METHOD
)♦I Aquifer Test DStonnwaterDrainage ft. ft. „
Experimental Technology O Subsidence Control ft. ft.
!Geothermal(Closed Loop) E3Tracer 011:11t1U1s1NGd 4iG;(attacfiaddinon ja56ee ifirece sn j)i ' ""
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
'Geothermal(Heating/Cooling Return) E3Other(explain under#21 Remarks)
0 ft. 92 ft. OVER BURDEN
4.Date Well(s)Completed:10-27-2023 Well ID# 92 fI 145, ft' GRANITE.
5a.Well Location: ft. ft. I —.
Edward Arnold Cabe ft. ft. _ .--- =Y,,r:_: .,J,,,:)
Facility/Owner Name Facility ID#(if applicable) ft. ft. I R'n 1/ q 22@23
288 Glen Cabe Road Sylva, NC 28779 ft. ft. IVI I U
ft. ft. IiiIC.7T. .'..^.11 r':. :. _- ": era
Physical Address,City,and Zip I ra,>! ,"w•
Jackson 7539-09-1576 A2i:8IE Olcs " - , ;
County Parcel identification No.(FIN) '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W 11-9-2023
6.1s(are)the well(s) X Permanent or Temporary Signa a of er ed anlnactor Date
By signing dr ornn,1 hereby certify'Mitt the well(s)was(were)constructed in accordance
7.is this a repair to an existing well: ®Yes or x No with 15,4 NCAC 02C.0100 or ISA NCAC 02C.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 till remarks section or on the buck 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
9.Total well depth below land surface: 145 (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@200'and 2(a l00') construction to the following: i
10.Static water level below top of casing:25 (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 addition to sending the form to the address in 24a
ROTARY above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger.rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 20 Method of test: RIG 24c.For Water Supply&Iniectio I Wells: In addition to sending the form to
the address(es) above, also submit jone 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.
1
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 2-22-2016