GW1-2021-06494_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD For Intemal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Sawyers 14.WATER ZONES
FROM TO DESCRIPTION
Wel I Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING'for multi-cased Wells)OR LINER if a `licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 56 ft- 16.25 i" #21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2021-00386 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: rt. ft. in.
List all applicable well permits(i.e.(burry,State,Variance,Injection,etc.)
ft. ft. in.
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) EIResidential Water SuPPIY(single) f. f. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) `18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL 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.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sail/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft- 56 ft. OVER BURDEN
8-25-2021 56 ft- 145 ft- GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft.
Cole Riddle LLC ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
326 Walnut Ridge Lane Weaverville, NC 28787 ft• ft. r
Phvsical Address,City,and Zip 21.REMARKS
Buncombe 9733964325 ocessln t
County Parcel Identification No.(PIN) p CsecI�
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: r�
(ifwell field,one]at/long is sufficient)
N `,1, 9-2-2021
Signature ofCcrtifJd Well Contraclid Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this fibrin, I hereby certify that the well(,)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Con.siruction S7andards and that a
7.Is this a repair to an existing well: ❑Yes or FINo copy ofdtis record has been provided to the well owner.
ll'dtis is a repair.Jill out known well construction in/ormation and explain the nature of the
repair under 21 remo ks.section or on the back q/'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.
1.or tmdtiple injection or non-water supply wells ONLY with the same construction,you can
submit one.larm. SUBMITTAL INSTLICTIONS
9.Total well depth below land surface: 145 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
P'or mulople we//s'list all depths ijdiJJerent(example-3@200'and 2@100') construction t0 the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
//vroter 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.) t
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method of test: RIG
24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
PILLS well construction to the county health department of the county where
13b.Disinfection type. Amount: 20
constructed.
I
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013