GW1-2021-03556_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
KOIb Sawyers 14.WATER Z.ONES � -
y yerS FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells'OR LINER if a 'lieable
FROM T 3 DIAMETER THiCKNE55 MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. 22 ft- 16.25 #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2021-00018 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable hell permits(i.e.County,State,Variance,Injection,etc)
ft. ft. iu.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPIY(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) --18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 It. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19 SANWGRAVEL PACK ifapplicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20:DRILLING LOG<attach additional shiets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 22 ft OVER BURDEN
$-2-2021 22 ft 405 ft GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft. y\
Round Table LLC ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
12 Overlook Place Asheville, NC 28803 ft. ft, res
Phvsical Address,City,and Zip f W
21:REiviARKS
Buncombe 9645-96-7182 ,��
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient)
N W 8-9-2021
/� at
Signature-of're—rtilIq Well ContractdIJ Date
6.Is(are)the well(s): ZPermanent or ❑Temporary By signing this.form,I hereby certify that the well(s)was(were)constructed in accordance
with I SA NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofthis record has been provided to the well owner.
l/this is a repair,fill out known well construction information and explain the nature of the
repair under 421 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: 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 lbrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 405 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells/is/a//depths iJ'dii ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 40 (ft) Division of Water Resources,Information Processing Unit,
l/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 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
m 13a.1'ield
(gP ) 20 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: 35 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

Well Driller Self-Grout Certification
a"'LlOwner: Hai �k C)
- New Well.
Address:_��-(�� k' ��.
Permit: Z 0 z O -- O U) 3 o)
I hereby certify that the above referenced well was grouted in appearance in aoaordance with
all County Well rules.
Well Driller• " 'K& Wc4d �' -)
Signed:
Certificate#: 0 H 3 -A Date Grouted: C0-!( -ZZ(
Construction: Gm.ut.-
Total Depth: S_ 'I' pe:
Casing Type: mckness: V'n ,'Y-,c d
Casing Depth: S-2-- Depth.: Q0
Diameter:_
weight/Thick:
Height:
Drive Shoe:
GPM. ��