GW1-2021-06474_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
KolbSawyers 14.WATER ZONES
y y FROM TO J DESCRIPTION
Well Contractor Name ft. ft.
4471-A
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-cased:wells .0 LINER if a lieable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 30 ft- 16.25 i" #21 PVC
Company Name '16.INNER CASING OR TUBING eothermal closed-loop)
2021-00025 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: fr. ft. in.
List all applicable hell perntis(i.e.County,Stare,Variance,Injection,etc•.)
ft. fr. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER 'SLOTSIZE THICKNESS MATERIAL
ft. ft. 4in❑Agricultural ❑Municipal/Public❑Geothermal Heatin /Coolin Su I ElResidential Water Su I (sin le ft. ft.
( g g Supply) Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrrigation 0 ft' 20 ft- Bentonite Pumped
Nun-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PAC K if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
120.DRILLING LOG'attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soit/rock type,grain si r,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fit- 30 ft. OVER BURDEN
4-27-2021 30 ft. 270 ft- GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
PMC Inv of WNC LLC ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
58 Shuler Road Candler, NC 28715 Cj
ft. ft.
Phvsical Address,City,and Zip 21.REMARKS
Buncombe 9606-75-7330 aeon r ; n
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(it well field one lat/long is sufficient)
N W 8-31-2021
Signature ofCe f d Well Conff or - Date
6.Is(are)the Ivell(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
ivuh I SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided to the well owner.
ll dus is a repair,fill out known well construction information and explain the nature gfthe
repair under 2/remarks.section or on the back o/'1hi.s fbrn. 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 wuinple injection or non-water.supply wells ONLY with the sane construction,you can
submit one./urn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 270 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
I-or multiple wells list all depths rJ*t#fereni(exc nple-3 cr 200'and 1@100') construction to the following:
10.Static water level below top of casing: 20 (g,) Division of Water Resources,Information Processing Unit,
1i ater 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.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.field(gpm) 100 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: 28 well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment attd Natural Resources-Division of Water Resources Revised August 2013