GW1-2021-01182_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:
KOLBY MITCHELL SAWYERS FRO
TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
NC Well Contractor Certification Number tS;.Utt21 A -''AStivt=.form ult>,cased cveils.OR-ilzlNgR, f a`Yrca7lTe;-:-
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS AND SON WELL +1 ft. 84 16.25 i" 1 #21 PVC
Company Name
1 „1}V1±IItSRCe#S11yG,bR,Tt7B1NC. ""thet7daTcfuserl Joo is ,,.,,. :::
2020-00397 FROM To DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,Statc,Variance,lnjecrion,etc.) . in
3.Well Use(check well use): ft ft
tI S,CRfENa...,:�
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public rt ft in.
❑Geothertal (Heating/Cooling Supply) BResidential Water Supply(sin(single) ft ft in.
❑lndustriaUCommercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Tiri ation 0 ft 20 ft- BENTONITE PUMPED
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 9c-SANDIGP PAt d:8' eatile F
❑Aquifer Storage and Recovery ❑Salinity Barrier
FRO5I ft. TO MATERIAL. E51PLACEME_NT METHODft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20:=3t1I11;Il�l� =ttCr attiie_Ti:adrfittiurtalsheeisrfarecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiltrock type.unin size,eta)
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 ft' 84 ft OVER BURDEN
ft. ft.
4.Date Weil(s)Completed: 03/02/2021 Well ID# 84 fr. 165 h GRANITE
5a.Well Location:
ft. ft.
Cole Riddle LLC
Facility/Owner Name Facility 1D#(ifapplicable)
317 Walnut Ridge, Lot 4 Ft 202
Physical Address,City,and Zip
Buncombe 9733-96-0597 rf� ►�n��� �l ,��{; , t�;cs,la
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
(if well field,one tat/long is sufficient)
N �,�, 1. 03-03-2021
WSipaci/tified7�Lell Contras Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this_form.I herehv c. l that the wellts)was(were)constructed in accordance
with I SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Hill Construction Standards and that a
7.Is this a repair to an existing well: ElYes or ❑No copy of this record has been provided to the well owner.
If this is a repair,fill out known>-ell construction in%rmatiun and explain the nature of the
repair under#21 remarks section or on the back(f this_brm. 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: 1 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: 165 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dilferenl(example-3@200'and 1(a1001 construction to the following:
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
Il 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(gpm) 12 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: 10 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