GW1-2021-01181_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD For Internal Use QNLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
DERRICK HEATH SAWYERS FRO1%r R ES .�.._u x CRfPF �.--
FROM TO DESCRIPTTON
Well Contractor Name ft. ft.
2436-A
NC Well Contractor Certification Number
1 ..t3t1. " tx foruttl c s¢e[(s OItt#9t tt=is Ircab[e
FROM TO I DIAMETER THICKNESS I MATERIAL
CLYDE SAWYERS AND SON WELL +1 ft. 48 ft. 6.25 '" #21 PVC
Company Name 3t:,11y1?IER f tlr15R,f#RT145. tliet�iiiF atoll ---- .-.:.
2019-00389 FROM 'I0 DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft.
List all applicable ivell permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) it. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply,(shared) 2g: Oi13._....
FROM TO MATERIAL RMPLACF.MFNT METHOD&AMOUNT
Elfi-rigation 0 et• 20 ft- BENTONITE PUMPED
Non-Water Supply Well:
ft. tL
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.iSsthtAtPAtifc' a ttite..h_�,. _G. ? ....____
FROM I To NIATERLU J EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
�24�- Ifal�l _=DG nit��eli ii�fii'`°"�ES`heets if lettssa -�=
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/ruck tv a gnin size,etc.)
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 ft' 8 ft• OVER BURDEN
02-05-2021
4.Date Well(s)Completed: Well ID# 48 ft• 105 ft• GRANITE
5a.Well Location: ft. rt. ti
Robert Mackey ft. fr.
Facility/Owner Name Facility ID#(if applicable)
ft. fr. 21
275 Brooks Cove, Candler 28715 ftow 1.9
Physical Address,City,and Zip tt°�
Buncombe 9608166830 ,".1
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwe0 field,one ladlong is sufficient)
N W 02-05-2021
Signarure o Certified Well Contra t
6.is(are)the well(s): OPermanent or ❑Temporary
By signing this firm,1 berths ce .�that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 sA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy of this record has been provided to the well nwter.
If this is a regain fill uut known well construction information and explain the nature of the
repair tinder#21 remarks section or on the back ofthis form. 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: 105 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths if dilferenl(example-3(V00'and 2(ag100') construction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
If imiater level is above casing.use••+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection 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
50 RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: 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