GW1-2021-01179_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:
DERRICK HEATH SAWYERS 24..3PtC� S ...... :..�A..� ..-_ -- -...... �._m
FROM TO DESCRFPTION
Well Contractor Name ft. ft.
2436-A
NC Well Contractor Certification Number 1 '' t1 Ltbli''fi°ratratEi'easotl wetfs OR"L11!1giL f itea7tie'z.'
FROM TO I DIAMETER TIHCKNF.SS MATERIAL
CLYDE SAWYERS AND SON WELL +1 ft- 101 ft- 6.25 1'- #21 PVC
Company Name #�-1iylYER CRS1lG bR[t3$IN 4QtHieeriiaifillisCd ipb «. - _;. :..:.
2020-00195 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt. in.
List all applicable well permits(i.e.Counrv,State,Variance,ln/ection,etc,) ft. ft. in.
3.Well Use(check well use): IT SG1tEEN... _
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
f[.❑Agricultural ❑Municipal/Public ft. in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single)
❑IndustriaUCommercial ❑Residential Water Supply(shared) AW ...,..
FROM TO MATERIAL F,MPLACF.MF.NT METHOD&.AMOUNT
❑hri ation 0 et• 20 ft- BENTONITE PUMPED
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Grouudwater Remediation IZxRA _....
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
:2fi 11 iill!ICy:, G ttactiaaaltitii a .is ifessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/o k type. rain size,etc.)
❑Geothermal(Hearing/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 101 ff• OVER BURDEN
02-04-2021
4.Date Well(s)Completed: Well 1D# 101 ff• 225 ft• GRANITE
5a.Well Location:
Kansas Hughes
Facility/Owner Name Facility ID#(ifapplicable) _
93 Gibbs Rd, Leicester 28748 F. A
Physical Address,City,and Zip a
Buncombe 470200575 --
d
County Parcel Identification No.(PIN) �� r,sn�c3ss�'(t(,j yj'J eeA
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N WAM 02-04-2021
Signature o Certified Well Contrak14'
6.is(are)thewell(s): 2Permanent or []Temporary By signing this jinn 1 herehv ce that the well(s)was(were)constructed in ucrordanre
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Nell 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 well owner.
If this is a repair,fill out knuim well construction information and explain the nature of the
repair under#21 remark-section or on the back r fihis(rrm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if tl Jferent(example-3(d200'and 2(a l00') construction to the following:
10.Static water level below top of casing: V O (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use•'+'• 1617 Mail.Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection 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,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.Yield m 10 Method of test: RIG 24c.For Water Supply&Injection Wells:
(gP ) Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: PILLS Amount: 20 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013