GW1-2021-01500_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolb Sawyers 14.WATER ZONES
Y Y FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471 A ft. ft.
NC Well Contractor Certification Number -15.OUTER CASING for multi-cased Wells OR LINER if a gieable'
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 1130 ft 6.25 i" #21 1 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2019-00505 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. i"•
List all applicable Ire/l permits(i.e.CounOt State,Variance,Injection,etc)
ft. 1
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. fr.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG:attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sin,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) 0 ft- 130 ft. OVER BURDEN
10-16-2020 130 fr• 265 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
Carolyn Pike ft. ft. Y V
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Berry Hill Road Asheville, NC 28806 ft. ft. M
Phvsical Address,Citv,and Zip 21.REMARKS
Buncombe Information Proces3ing dill,
County Parcel Identification No.(PIN) DV-v `Sed
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(it'well field.one lat/long is sufficient)
N w � � �� 1-11-2021
Signature ofCcrtil a Well Contract Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,1 hereby certify that the well(ti)was(were)constructed in accordance
with 15A NCAC 02C.0100 or/SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofthi.c record has been provided to the well owner.
1 j this is a repair/ill out known well construction information and explain the nature of the
repair under 21 remarks section or on the back oJ'this forin. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-waters'upply wells ONLY with the same construction,you can
SUBMITTAL INSTUCTIONS
submit oneJitrnt
9.Total well depth below land surface: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
/yin•nm/tip/e Ire//.c list a//depths i/'diJ)erem(exanrp/e-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
//hater level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b. For Iniection 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
13a.field(gpm) 20 Method of test: RI
24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 25 well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013