GW1-2021-01167_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 FR.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name R, ft.
4471-A rt. ft.
NC Well Contractor Certification Number 15,OUTER CASING(for mulrr-cased wells OR LINER if o -licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS AND SON WELL +1 rt. 133 fi 6.25 i" #21 1 PVC
Company Name 16.INNER CASING ORTIJBING(geothermal closed-loop)
2020-00433 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. fr. in.
List all applicable irell perntii.s(i.e.C'aunht Slate,Variance,injection,etc.)
it. 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
it. ft. in.
❑Geothermal(Heating/Cooling Supply) DResidential Water SuPPIY(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. it.
❑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. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG lactateh additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soillrock type,grain sin,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 fr' 133 it OVER BURDEN
4.Date Well 12-17-2020 s)Completed: Well ID#
133 fr 365 it GRANITE
5a.Well Location: fr. rt.
JACKIE HANEY ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. Y ��
s �
49 MAG SLUDER ROAD LEICESTER, NC 28748 ft. ft.
Physical Address,City.and Zip '21.REMARKS V
BUNCOMBE 9722100448
n:•... r,. aaai i 3r
County Parcel IdentiflcationNo.(PIN) IGIVt��crc+4:: •�r• �+
act;
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(il'well field,one[at/Ion,is sufficient)
N W o 01-25-2021
Signature ofCerti d Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this Jorm,I hereby certify that the we/l(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided to the wel/owner.
1/this is a repair,Jill out known well consirnclion inlormaiion and explain the nature o/'the
repair under.21 remarks.seeiion or on the back of this fi rm. 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.
1-br multiple injection or non-firmer supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 365 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
/-'or nnitople:cells list all depths ifdt(Jerem(example-3@200'and 2 ct 100') construction to the following:
10.Static water level below top of casing: 50 Division of Water Resources,Information Processing Unit,
if user level is above casing,live"F ' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b. For Injection Wells ONLY: In addition to sending the form to the address in
ROTARY AIR 24aabove, 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,rotaq•,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.Yield(gpm) 1 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: 35 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 201