GW1-2021-03610_Well Construction - GW1_20210823

WELL CONSTRUCTION "CORD For Internal Use ONLY:
This form can be used for single Or Multiple Wells
1.Well Contractor Information:
�14.WATER!,'ZONES
Kolby Sawyers FROM TO DESC PT.I"PTION
1 .I
Well Contractor Name ft.
4471-A
1.5.OUTER CASING for 711�Lcaie I d,,"w I Is)rL.1CN=,I a icable)
E L
NC Well Contractor Certification Number FROM I TO DIAMETER. THICKNESS
MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 f- 123 fi`- 16.25 1 in. 1 #21 PVC
i
Company Name A6.INNER CASING OWTUBING, eothertnat closed4690)w,-
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 202 1-00224 ft. ft. in.
List all applicable well permits(i.e.County,State.Variance,Injection,etc.)
in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
in.,
OAgricultural DMunicipal/Public in.
OGeothermal(Heating/Cooling Supply) EIResidential Water Supply(single)
Olindustrial/Commereial OResidential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
11fi-rigation 0 f" 20 ft- Bentodite Pumped
Non-Water Supply Well:
DMonitoring ORecovery
Injection Well: ft. ft.
0Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK_(if applica 16)
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery OSalinity Barrier
CAquifer Test OStormwater Drainage
DExperimental Technology D Subsidence Control
,10.DRILLING LOG(attach additional sheets if necessar
y)
DGeothennal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) 0 ft- 23 ft. OVER BURDEN
08/09/2021 23 505 GRANITE
4.Date Well(s)Completed: Well ID# ,�,\ l
5a.Well Location:
Bpbby Deaver ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
74 Hobson Br. Rd.
Physical Address,City,and Zip �''�21.REMARKS-,,,
Buncombe 975620588900000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certiffic
(if well field,one]at/long is sufficient) r17 ) C 08/09/2021
N W
ignature oft-elff-J�Well Contract Date
IV i
6.Is(are)the well(s): 2Permanent or OTemporary By signing this form,I hereby certifv 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: OYes or ElNo cop),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 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
8.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 oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 505 —(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiflerent(example-3@200'and 2@100') construction to the Following:
10.Static water level below top of casing: 30 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 Infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ROTARY 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 enter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: RIG 24c.For Water Supply&Injection I on Wells
Also submit one copy of this 15orrP� within 30 days of completion of
, I
13b.Disinfection type. PILLS Amount: 30 well construction to the county health department of the county where
constructed.
Forfa GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013