GW1-2021-06487_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:
KOLBY SAWYERS 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER ifa Iieable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 28 16.25 i° #21 1 PVC
Company Name 16♦INNER CASING OR TUBING eothecmal closed-loop)
2021-00531 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable irell permits(i.e.County,Slate,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 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:
ft. rt.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL'-PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary).
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness soiltrack type,gritin sin,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 28 ft OVER BURDEN
10-11-2021 28 ft 1105 ft GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
Wayne Galloway ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Elk Trail Asheville, NC 28804 ft. ft. 2LuLl
Physical Address,City,and Zip 21.REMARKS f1 t
Buncombe 976133030400000
County Parcel Identification No.(PIN) ' p
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if sell field,one lat/long is sufficient)
N W �O � AD��� 10-15-2021
Signature of Certifi d ell Contract(r) Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy ofthis record has been provided to the well owner.
1llhi.s is a repair/ill out known well construction hilarmation and explain the nature oflhe
repair under:!21 remarks section or on the back q1*lhisJorm. 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.
hor multiple injection or non-water supply wells ONLY with the same construction,you can
suhmit one/nrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 1105 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
1-or midtiple wells list all depths i/'different(example-3@100'and 2@/00') construction to the following:
10.Static water level below top of casing: Dry (ft.) Division of Water Resources,Information Processing Unit,
l)lrater 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.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.field(gpm)
0 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: 35 well construction to the county health department of the county where
constructed.
Font GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013