GW1-2021-06475_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:
Kolby Sawyers 14:WATER ZONES,
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FROM TO DESCRIPTION
Well Contractor Name
4471-A
NC Well Contractor Certification Number 15.OUTER,CASING for mull'cased!wells`OR LINER if s' lieable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 36 ft• 6.25 '" 1 #21 1 PVC
Company Namc 16.INNER CASING ORTUBING eothermal closed-loop)
2019-00229 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: tt. ft. in.
List all applicable well permits(i.e.County,State, Variance,h jection,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 in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT ;
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[Irrigation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
rt. rt.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHODft. ft.
❑Aquifer Test ❑Stormwatcr Drainage
ft. ft.
❑Experimental Technology El Subsidence Control
20.DRILLING LOG attach additional'sheets if necessary).
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock typc rain sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 36 ff• OVER BURDEN
08/30/2021 36 ft 205 ff• GRANITE
4.Date Well(s)Completed: Well ID#
tt. tt.
5a.Well Location: ft. ft.
Sandra Franklin ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
Snelson Rd. ICI.
Physical Address,City,and Zip
Buncombe 9724537252 zr::REMARxs In{ormat.oii`� Sgcjion
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certitic on
(if well field,one lat/long is sufficient) •
N � C 08-30-2021
ignature oC a tP Well Contract Date
6.Is(are)the well(s): ❑✓Permanent or ❑Temporary By signing this form,I hereby cerlifv that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo cony of this record has been provided to the well owner.
Lf 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 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 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: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'attd 2@100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
lfwater 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.Yield m 10 Method of test: RIG 24c.For Water Supply&Injection Wells:
tgP ) 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: 30
constructed.
V
Form GW-I North Carolina Department of Environment and Natural Resources—Division of WalerResources Revised August 2013
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