GW1-2021-01502_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
KOLBY SAWYERS 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ".
4471-A ft. I ft.
NC Well Contractor Certification Number 15.OUTER CASING"for multi-cased wells OR LINER if a` licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 98 It. 6.25 i" #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM
2.Well Construction Permit#: 2020-00316 ft TO ft DIAMETER in.
THICKNESS MATERIAL
List all applic•ahle irell pernius(i.e.County.Slate,Variance.Injection,etc.)
ft. ft. in.
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) 1S.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 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)
❑ y ❑ FROM TO Aquifer Storage and Recover), Barrier ft. ft. MATERIAL EMPLACEMENT METHOD
OAquiter 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 soiVrock type,grain sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 98 ft. OVER BURDEN
1-11-2021 98 ft- 205 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft. a,
R&S INVESTMENTS
Facility/Owner Name Facility ID#(ifapplicable) ft.
ROLLING HILLS OF FRENCH BROAD LOT 2 ASHEVILLE
Phvsical Address,City,and Zip 21.REMARKS z tlit
BUNCOMBE 9721184263
County Parcel Identification No.(PIN)
511h.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one ladlong is sufficient)
N N, IA. 1-12-2021
Signature of C fie t ell Contr r Date
6.Is(are)the well(s): ©Permanent or ❑Temporary by signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0I00 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or El No copy ofthis record has been provided to the well owner.
I/'ihis is a repair.Jill out known well construction information and explain the nature of 1he
repair under o2I rentarkc section or on the hack o/'this farm. 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 injec•lion or non-waler supply wells ONLY with the sane construction,you can
suhnni one./brnt. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
bor mulliple wells list all depihs ifih erenl(example-3@200'and 2 cd I00') construction t0 the following:
10.Static water level below top of casing: 50 Division of Water Resources,Information Processing Unit,
of water level is above caging,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) $ Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 20 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