GW1-2021-01503_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:
r
KOLBY MITCHELL SAWYERS
FROM TO T�DESCRIPTION
Well Contractor Name ft. fr.
4471-A ft. fr.
NC Well Contractor Certification Number
,.OtI 1ID.toi auelrs U i l>VEIt` f resort
FROM TO DIAMETER THiCKNF,SS AfATF.Rl.4i.
CLYDE SAWYERS AND SON WELL +1 ft. 135 ft. 6.25 #21 PVC
Company NameN#lfR Cunt{2I�,f1113V .'}he!'>t3><Itrisellrlott _- -------• --- ---°�----=
ZO1 Q V—O FROM DIAMETER. THICKNESS DATERIAL
2.Well Construction Permit#: 0490 in.
List all applicable well permits(i.e.County,State,Ya•iahee,Injection,etc.) ft. ft. in,
3.Well Use(check well use):
tt SGRE))V _.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERI.L
fr. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft. fr. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ftt-
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑li-ri ation 0 et. 20 fr• BENTONITE PUMPED
Non-Water Supply Well:
ft. tt.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19..Si1i` 1G'RA srF1L.RAL Ifi ff•a cable ...._....... °�..._3,is ... .
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
211.-Di�: <f�,a€taelf:a�t r:-"'l:slt�f4: a�ressacv °; _
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/mk tv a rain size,etc.
❑Geothermal Heatin Coohn Return El Other(explain under#21 Remarks) 0 ft• 135 ft• OVER BURDEN
01/27/2021
4.Date Well(s)Completed: Well 1D#
135 ft• 265 fr• � GRANITE
59.Well Location:
ft. ft.
Brad Roger Builders, LLC
Ifs lie ble Facilit/Owner Name Facilit ID#
Y r:Y ( PP tl ) if
139 Ridge Road, Candles ft.
Physical Address,City,and Zip 2J,.ItiVThR-tf ._. ' t
Buncombe 8698671429
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one ladlong is sufficient)
02-19-2021 N `tlt 14
Sigzta ntified Well Contd"t
Date
6.is(are)the well(s): OPermanent or ❑Temporary 13y signing this fin l herehr c hat the wells)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Cormtruc•fron Standards and that a
7.Is this a repair to an existing well: OYes or ❑No copy ofthis record has been provided to the well owner.
If this is a repair,fill uut knutvn well construction information and explain the nature of the
repair tinder#21 remark'section or on the back t fthis,furm. 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: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiJfe•ent(example-3@200'and 2(a.1001 construction to the following:
10.Static water level below top of casing: 30 (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 Iniection 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 27699AI636
13a.Yield(gpm) 7 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days ofcompletion 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 Enviropment and Natural Resources—Division of Water Resources Revised August 2013