GW1-2021-06477_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:
f, WATER16NE9-
DERRICK HEATH SAWYERS
FROM TO DESCRIPTION
Well Contractor Name ft, ft.
2436-A
NC Well Contractor Certification Number IS:OUTER CASING,tor'.,u ally'taiwgwelts.OR'LINER z4
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS AND SON WELL +1 it• 97 it 6.25 in #21 1 PVC
Company Name
I6:'INNER'CASIIVGURTUBING;"i(thirinaLclosed-lpn a
2021-00219 FROM ft. TO DIAMETER THICKNESS MATEAL
2.Well Construction Permit#: ft.. in. RI
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(sin(single)
1tir`""GROUTS . a . . 777777 .:.....:_
❑lndustriaUCommercial ❑Residential Water Supply(shared) ,,, L
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20 ft. BENTONITE PUMPED
Non-Water Supply Well:
ft. tt.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19:'SANDIGRAL'PACK;
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control a _.„ -,F
20.?DRfLL1NG�IQG attach addlhou'at sheets ifnecess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gnin size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 n. 97 rc. OVER BURDEN
it. ft.
4.Date Well 08-27-2021 s)Completed: Well H)#
97 ft 305 ft GRANIT
5a.Well Location: ft. tt. IV
Floyd Williams
r
Facility/Owner Name Facility ID#(if applicable) ft. ft.
25 Ridge Hill Rd. ft. ft. ressillc�Ul
n
Physical Address,City,and Zip Pro..
,3I REMARKS;? � ° QGI a
Buncombe 070093111800000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one ladlong is sufficient)
N W S at 08-30-2021
Signature o Certdied Well Contra t
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,I hereby ce ify 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: ❑Yes or E]No cop},of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature arthe
repair under#21 remarks section or on the back ojthis 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: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiJferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 60 Division of Water Resources,Information Processing Unit,
Ifwater 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 AIR 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(gpm) 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. j
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013