GW1-2021-06080_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
DERRICK HEATH SAWYERS FROM FROI\1 TO DESCRIPTION
Well Contractor Name ft. ff.
2436-A
rr fJ,(1`GirA`,1#t for�"tltl • i15 Ot2xLl1,E a�8 '#i�Tc.
R
NC Well Contractor Certification Number
FROM TO DIAMETER- THICKNESS I MATERIAL
CLYDE SAWYERS AND SON WELL +1 ft. 96 fl. 6.25 in. #21 PVC
Company Nameil!IIt r111815�`, 4 in(t
2018-00493 FRODI 1O DIAMETER I THICKNESS alATERIAI,
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Counn•,State,Variance,Injection,etc.) ft tt in
3.Well Use(check well use):
12:'GREI
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaL/Public ft. ft. In.'
❑Geothermal (Heating/Cooling Supply) BResidential Water SuPPIY(single) R ft in..
❑lndustrial/Commercial ❑Residential Water Supply(shared) � �
FROM TO MATERIAL ,EMPLACEMF.NT MF,TROII&.AMOUNT
❑hri anon 0 ft. 20 it. BENTONITE PUMPED
Non-Water Supply Well: R ft
❑Monitoring ❑Recovery
Injection Well:
❑AquiferRecharge ❑CroundwaterRemediation
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer FRO1%1 TO DESCRIPTION color,hardness,soil/o k ry e grain size,etc.
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 er. 96 it. OVER BURDEN
et. ir.
4.Date Weil 02-04-2019(s)Completed: Well 1D#
96 ft 305 ft GRANITE
5a.Well Location:
THOMAS WHITFIELD
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
IV
624 BEAVERDAM RD ASHEVILLE, NC
ft. R.
Physical Address,City,and Zips ,.
Buncombe 9750570658
County Parcel Identification No.(PIN) jZinn prYSOn
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N 07-07-2021
Signature o Certified Well Couvrif"
6.is(are)the well(s): OPermanent or ❑Temporary
By signing this Jinm.!herehv cethut the a,ell(s)was(were)constructed in accordance
with I SA NCAC 02C A100 or I5A NCAC'02C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo ropy of this record has been provided to the well owner.
If this is a repair,fill uut knoim well cunstruction infurntation and explain the nature of the
repair under#21 remarkv section or on the back r fthis 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: 305 —(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iij'differeni(example-j(qj200'and 2(a,100') construction t0 the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
It.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY: It 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: constriction 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:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 25 well construction to the county health department of the county where
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resutvices Revised August 2013
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