GW1--05615_Well Construction - GW1_20240916

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
Derrick Heath Sawyers 44.A11cTstut ivl; n ,.goc n : . ramwarmm m}* . = , r
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2436-A ft. ft. h
NC Well Contractor Certification Number s;1SADI tt t+wa iNa(faiiiitiltl caietttii�elts);ORi4jNCR{ifia"p lieabl`er a
FROM TO DIAMETER I THICKNESS MATERIAL.
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt• 81 rt• 6.25 i i"• #21 PVC
Company Name I o •
1G.41NiNtR G'i S11YCROR,T,t;llilN(r(geu erinul ctos6d ti o(t}�r�t" i`"3'"� er. > ,�
GJS-192W FROM 'CO DIAMEtER THICKNESS MATERIAL.
2.Well Construction Permit#: fL ft. ' in.
List all applicable well permits(i.e.County,State,I'ariance,Injection,etc.) ft. ft. 1.
in,
3.Well Use(check well use): Ol xSCREGIY :3r,< N ;V'Y:`M'MV *.`ux M ' .,. z .WC . .:..
;:
��''atC'1'Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.l
❑Geothermal lleatin g/Coolin Supply) ©Residential Water Supply(single) ft. ft. in.,
( 6 g PPY) PPY( g
,1R".'•'GRUtiliO ':9£`MMV: `*;t �r`axe,;+r?=k' ,141 .AM .'W' ;'w �"'".- `� ,0...:,kt" "
❑hidustrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD B:AMOUNT
❑liTigation 0 ft' 20 ft• Bentonite Pumped
Non-Water Supply Well:
ft. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
injection Well: ft. ft. ,
❑Aquifer Recharge ❑Gromtdwater Remediation 19,.SA1V111CR VEL`':l'AGISS(if.a(iplit file), .'?", „; ,°,,"a, ,, rs,,.';AWI Sea
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft. 1
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control •
., t;
24::iii)1L11010 f1G(attach idditidniit�stie'tiff neressaru) .* :`'a .,,�:.: t".°
❑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• 81 ft. c OVER BURDEN
7-31-2024 81 ft• 525 ft• GRANITE
4.Date N'ell(s)Completed: ---Well ID#
ft. ft.
5a.Well Location: ft. ft.
GREG WISHART •
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft, ft.
82 WISHART WAY CLYDE, NC 28721 ft. ft.
Physical Address.City,and Zip 41 1.12F. ^1UKSWOM ,) r`;€A,3 a` 5 x 0?: ,kr is i'
HAYWOOD 8627-52-2316
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(if well field,one lat/long is sufficient) I
N W 8-5-2024
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Signature of ertified Well Contract() f`^� Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)
us ( wre ors �th#n�af r9'nTc
with I SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Cot st,-uc ttin ,ndal'ds fluid u a
7.Is this a repair to an existing well: ❑Yes or ENo copy of this record has been provided to,the well ou7ter. S E P 1
If this is a repair,fill out known well eontsb-uelimt information and explain the nature of the 6 2024
repair under#21 remarks section or on the back of firm. 23.Site diagram or additional well details:
You may use the hack of this page to providi-,tfc�d igt{Sll.,rsyeej ite0details or well
S.Number of wells constructed: 1 construction details. You may alsojattach additional pagep Eire '�.y t .'
For multiple injection or non-water supply wells ONLY with the.same construction,you can ��
submit one form. SUBMITTAL INSTUCTIONS j
9.Total well depth below land surface: 525 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdilferent(example-3(a,200'and 24100') construction to the following:
10.Static water level below top of casing: 80 (fL) Division of Water Resources,Information Processing Unit,
limiter level is above casing.use"+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY 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.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
1 RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
PILLS Also submit one copy of this fo''m within 30 days of completion of
13b.Disinfection type: Amount: 35 well construction to the county Ilea th department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Wate4esources Revised August 2013
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