GW1-2021-06491_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Heath Sawyers 14.WATERZONES'
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2436A ft. ft.
NC Well Contractor Certification Number 15:OUTER CASING focmulti-cased"wells OR LINER if a""licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 89 fit- 6.25 #21 PVC
Company Name 16.INNER CASING OR TUBING iothermal:'closed-loop) ,t ", ,....
77—
2021-���20 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable ire/l permits(i.e.County,Stale,Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPIY(single) f. ft. in.
18.'GROUT
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
El Irrigation 0 ft. 20 f`- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILI1 G,LOG attach additional:sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness soil/rack type,grain sim,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 89 ft. OVER BURDEN
7-26-2021 89 f`' 225 f`' GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
Jesus Nunez
ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. '
Cleaves Drive/Morgan Cove Candler, NC 28715 Sr V11
ft. ft. "'QUO
Physical Address,City,and Zip 21.REMARKS 1l
Buncombe 8686686412 MNR
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one hit/long is sufficient)
N W � 9-10-2021
Signature of Certified Well ContracUr Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By,signing this form,I hereby certtt�that the ivell(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 END copy of This record has been provided to the[veil owner.
Il this is a repair,(ill out known well construction information and explain the nature of the
repair under 21 remarks section or on the back o/1his 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.
Liar nndliple inieclion or non-water supply we/ty ONLY with the same construction,you can
suhnil one,/ono. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
1,or multiple wells list a//dcplhs if different(example-3@(200'and 2 a@100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
I/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
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.anger,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) 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: 30 well construction to the county health department of the county where
constructed.
Form G W-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013