GW1--05624_Well Construction - GW1_20240916

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
I . •
Kolby Mitchel Sawyers aWAlrl,rifzortics, sM > '. 0_ `: % .Y ;- . Q
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft. k
NC Well Contractor Certification Number
CLYDE SAWYERS & SON WELL & PUMP INC 4FRONI fGRUaSI t>(for iiultteTEPEe ► OTI ICK ESS hMAT ���<. . °>`
xROnI co 'HASTE PER IUICKrviSS n)nrr•.Rtni
+1 ft 90 R. 6.25 in. #21 PVC
Company Name . •1
2024-26206-9-13495 61TNERRCAstNGOi�.Trull[NGgei',thernal;ctosed-loop z. :�::
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable tie!!construction permits(i.e.UIC.County.State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
14. SCR'ELN/e x•Mx#�' .A ' 'c `I shy i. aW, t�s �xx ,T,'," .t , O
it
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in'.
Geothermal(Heating/Cooling Supply) .Residential Water Supply(single) ft. ft, in:
industrial/Commercial Residential Water Supply(shared) jRUU.T< ,.. xk ,� zx'4h
(Irrigation FROM TO M.1'1'ItRIAI, x:hI P1,ACx;MIRN'1'METHOD&AMOUNT
Non-Water Supply Well: 0 It 20 ft. Bentonite Pumped
Monitoring Recovery ft.ft. 1't. Cap Top with Bentomite chips
Injection Well:
Aquifer Recharge ;Groundwater Retnediation �r _ s
A19 SAND/GRA1?-EL7!c M:lit iippliii t le faMb ,.`s M k�$'>'`, ki
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test StomiwaterDrainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer .t'l40.4)AtITAANGT(SalidifikiiIiiirdliiiiiilriliattifife'e6iliii)%1MINalitNiginl
FROM TO DESCRIPTION(color.hardness,soil/rock type.grain vac,etc.)
DGeotherma (Heating/Cooling Return) 0Other(explain under#21 Remarks)
0 ft. 90 ft. OVERBURDEN
4.Date Well(s)Completed:8-23-2024 Well ID# 90 ff. 165 ft• GRANITE
ft. ft. '
5a.Well Location: .
WHITNE MATHIS ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1066 CRAWFORD CEMETARDY ROAD SYLVA, NC 28779 ft. ft.
Physical Address.City,and Zip ft. ft•
JACKSON 7673-35-9176 21 1EiVATtiv5;S S V. ,<; ; >MZ , ` Y ;` x ),
County Parcel Identification 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' 8-28-2024
6.Is(are)the well(s) Permanent or DTemporary Signa a of C er ed onhucmr '— Date
By signing tlr.form,I hereby cc•rtii i'that the well(s)tins(a'crey cmrauneted in,atecz'rd v.:.7,4
7.Is this a repair to an existing well: DYes or ix No with 15.4 NCAC 02C.0/00 or 15A NCAC 02C'.0200 Well Coit',i litr0 tat rds'lrtrd urt�n. 1
If this is a repair,fill out known well construction information and explain the nature of the coin'of this record has been provided to due.arelt owner. �' "' �✓
repair under 021 renarks section or on the hack of this fen-m. 23.Site diagram or additional well details: S E P 1 1 b n ,1
2024
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 p r' STr.li.Iees,s14yr ram,;,r 1J
drilled: t SUBMITTAL INSTRUCTIONS, �'��°1.u'iI`UI
9.Total well depth below land surface: 165 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths!(l'diffcrent(example-3@200'and 2(a 100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resorces,information Processing Unit,
i/water level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 n.
(i ) 24b.For infection Wells: In addition to sending the form to the address in 24a
ROTARY above, also submit one copy of thus'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
i !
13a.Yield(gpm) 10 Method of test: RIG 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also subiriit 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.
Form CW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016