GW1-2021-01183_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 F4.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2436-A
NC Well Contractor Certification Number
I5.OUTER ACASINOffor,multi-eased"veils;OR LINER,il a °cable' ,, ,
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS AND SON WELL +1 ft. 75 ft. 6.25 1n #21 1 PVC
Company Name l6.INNER CASING:()R I UBING; eotberiaal closed too
2020-00444 FROM TO DIAMETER THICKNESS MATERIAL ~
2.Well Construction Permit#: tt. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft. ft. in.
well k h Well U W 3. ese(check we use):
_ 17.SCREEN
Water Supply Well: FROM TO DIAMETER _ SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) E IResidential Water Supply(single) ft' ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
01tri ation 0 ft. 20 fL BENTONITE• PUMPED
Non-Water Supply Well:
ft. w ft.
❑Monitoring ❑Recovery
Injection Well: ft, ft.
❑Aquifer Recharge ❑GroundwaterRemediation 14:5r�ND/GR?iS i PACK;da'"lleable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control
.20:DRILLING LOG attach additioual sheets'if uecess "" "
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness,soiltrock type,grain size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 75 tt' OVER BURDEN
ft. rt.
4.Date Well 03-02-2021 s)Completed: Well ID#
75 tt 185 tt GRANITE
5a.Well Location:
R & S INVESTMENTS ft. rL
Facility/Owner Name Facility ID#(if applicable)
Indian Paintbrush Ln., Lot #8 ft. ft. � r' _.°*V
ft. fL
Physical Address,City,and Zip 21.REMARK$: V ;
Buncombe 9721178385
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W 03-03-2021
Signature o Cerihfied Well Contra t
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby ce ify that the well(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 E!JNo copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 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: construction details. You may also attach additional pages if necessary.
For multiple injection or•non-wafer supply wells ONLY with the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a@200'and 2Q100') construction to the following:
10.Static water level below top of casing: 60 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 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.Yield m 15 Method of test' RIG 24c.For Water Supply&Injection Wells:
(gp ) 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