GW1-2021-01186_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 1�.: tari � y
FROM TO DESCRIPTION
Well Contractor Name
4471-A ft.
NC Well Contractor Certification Number 13-.t3ll I Eft• hS11tFG-for'xiulti-cased:we[Is:OR_LINER.fI Itcable
FROM TO DiAMF,TF.R THICKNESS MATERIAL
CLYDE SAWYERS AND SON WELL +1 ft- 1101 ft- 6.25 in. #21 1 PVC
Company Name
t:.1NNERfi' 11`rG 01i l r}S1NG- e0tlaernial;ctosed>too n;: r-;
2020-00396 FROM '10 DIAMETKIt THICKNFSS I MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIA11fETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in,
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) i8 GROt1T..;..
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hTi ation 0 ft• 20 ft. BENTONITE PUMPED
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.;5lI1Al(URAh3?elGist`d8" eYi7e❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stomiwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control
--�.$iTWY,1.fN(>:fORi RtfAeh�ad0ltiaittel`s'hPP.t5 idiaieeEY3at'Y::•: :.. -::.-->.�-_
❑Geothermal(Closed loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/roek tv a ram size,etc
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 ft• 101 ft OVER BURDEN
ft. ft.
4.Date Weil 03/01/2021(s)Completed: Well 1D#
101 ft• 285 ft• GRANITE
5a.Well Location:
Cole Riddle LLC
Facility/Owner Name Facility ID#(if applicable)
313 Walnut Ridge, Lot 3 A"
ft ft
Physical Address,City,and Zip `
21.REiyfARKS. :`
Buncombe 9733-96-0597 R „��,� �:,,� f.•,9cq , ;�
County Parcel Identification No.(PIN) +•u;•m s.o?S
va-i vc,•,l,f)�11
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifcation-
(if well field,one ladlong is sufficient)
N W 03-03-2021
Sigma eltified Welt Cuntrac Date
b.is(are)the we11(s): 2Permanent or ❑Temporary
By sibming thLr firm,/herehv e 'fy that the well(s)was(were)constructed in uceard mre
with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 14 ell Construction Standards and that a
7.Is this a repair to an existing well: OYes or ❑No copy of this 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 a 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
8.Number of wells constructed: construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-water supply wells ONL t•wi/h the same construction,you can
submit one form. p SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 285 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ij'diJferent(example-9 a 00'anel 2(a.100) 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 27699-1636
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: RIG Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 15 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