GW1--05613_Well Construction - GW1_20240916

WELL CONSTRUCTION RECORD For Internal Use ONLY: "
This form can be used for single or multiple wells
I.Well Contractor Information:
Derrick Heath Sawyers 41, 8 ATEItZQiy)`.mxe ar.> -i ?c'omw,Y _;* n,,- 4,'''''FROM TO DESCRIPTION
Well Contractor Name • ft. ft.
2436-A ft. ft.
'
NC Well Contractor Certification Number 1WOO tittiCSi1H0(Irbil Villi tl t4'elliMetiNEti{tit ticalile)`'' sue' :'s``'
FROM TO DIAMETER THICKNESS !MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft 140 it- 61/8 tit #188 STEEL
iCrrt 11VWCr3SfNdCif'1 UB1NGAeoth6iiiih.lowed-Inoli)'K; aWt
Company Name X
JMQ-320W FROM 'r0 DIAMETER THICKNESS MATERIAI.
2.Well Construction Permit#: ft. ft. 'r in.
•
List all applicable well permits(i.e.County,Slate.Ym•iance,Injection,etc.) II. ft. in.
3.Well Use(check well use): 1174802EI:N '• ~ ~4,,',"4 ` `'eft*ATkL ? �i# tx
Water Supply well: FROM , TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Publie
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply ft. [t. in.
( � g PpY) PpY
❑htdustrial/Commercial ❑Residential Water Supply(shared) 1,1118 iRUUT w ? '' �?W t` x.: x M % 4 h''
FROM TO MATERIAL EMPLACF.MRNT METHOD 8 AMOUNT
❑Irri gat ion 0 ft. 20 ft• Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft. Cap Top with Bentonite Chips
Injection Well: ft. ft: j
❑Aquifer Recharge El Groundwater Remediation A4<SANDIGftkVEL"IPAtsK'(if,a'(tt3lib3 t le}?A : .. :Matz. ,r4.4WZ ;
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier It. ft.
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology El Subsidence Control
2UaDRltil lN01;t1 toUacfi:ndditiolashcetsitnecessarv) K ,, M `
❑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- 140 ft• OVER BURDEN
8-2-2024 140 ft• 445 it. GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
ft. ft:
TYSON BRIGGS ft. ft.
Facility/Owner Name Facility IDS(if applicable)
ft. ft. •
75 CARTER MTN ROAD CLYDE, NC 28721 ft. ft.
Physical Address,City,and Zip J2liattN1A WS`iAN,} s 'a M:S •,w .c c'i z' ` g u
HAYWOOD 8732-94-5539 WELL WAS,SELF CERTIFIED
County Parcel Identification No.(PIN)
5b.Latitude and Longitude ill degrees/minutes/seconds or decimal degrees: 22.Certification: '
(if well field,one lat/long is sufficient)
N � 8-3-2024 _
YeOfCitifiedWCIICo&rIo C P�(' i i J C Li
6.Is(are)the well(s):-OPermanent or ❑Temporary By signing this firm,I hereby certify that the well(s)was(were sir led in cdrnu e
with 15A.NCAC 02C.0/00 or I sA NCAC 02C.0200 Well Cons J fn Sianerd Oernr24hat a
7.Is this a repair to an existing well: ❑Yes or IfI No copy of this record has been provided to the well ost71er•.
If this is a repair,fill out known well construction information and elplain the nature of the
repair under(/21 remarks.section or on the hack of frm. 23.Site diagram or additional well details: Ifif-a.. 'cA f ii T I rr" `ri y WA
You may use the back of this page to provide additional wnt`�3iea:rl t is or well
8.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:445 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if di/fermi(example-3(4)200'and 2(k100') construction to the following: i/
I'
10.Static water level below top of casing: 80 (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 ONLY:i,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.c.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
(gpm) 2 RIG 24c.For Water Supply Sc Injection Wells:
13a.Yield m Method of test:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 35 well construction to the county hi alth department of the county where
constructed.
I; '
Fornt GW-I North Catalina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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