GW1-2021-03590_Well Construction - GW1_20210823

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WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
K 14.WATER
Olby Sawyers
FROM 'to DESCRIPTION
Well Contractor Name ft. ft.
4471-A
NC Well Contractor Certification Number 15.OUTER CASING for-mint-eased wells OR-LINER if licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 20 ft 6.25 i" #21 PVC
Company Name
&INNER CASING OR:Td1BING thermal closed-140
2021-00256 FROM TO DIAMETER THICKNESS 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): 17.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL L EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 rt. 20 ft. Bentonite Pumped
Non-Water Supply Well:
rr. rt.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVFEL PACK:if a licd6le
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING I OG attach additionai sheets if necess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gmin size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 20 ft. OVER BURDEN
07/30/2021 20 ft 165 ft GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location:
Dennis Peek
Facility/Owner Name Facility ID#(if applicable)
v\1\
35 Crofoot Trail rt. ft. , � 5\.
Physical Address,City,and Zip 21.REMARKS
Buncombe 973126670100000 �,�' ��
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certific 'on:
(if well field,one fat/long is sufficient)
N \I 08-02-2021
ignature oC e h Well Contract Date
6.Is(are)the we6(S): ❑✓Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A 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 owner.
ifthis is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 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 alsolattach 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 ifdiftrent(example-3@200'and 2@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
i
11.Borehole diameter: 6.25 (in.) 24b.For Infection Wells ONLY:p 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: E
(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 m 8 Method of test- RIG 24c.For Water Supply&Injection Wells:
(gp ) Also submit one copy of this f661 within 30 days of completion of
13b.Disinfection type: PILLS Amount: 30 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