GW1-2021-00136_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
Kolby Mitchell Sawyers FR WATER
ZONES
OhI TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number 1S.OUTER CASING(for multi-eased wells)OR ER`(ifa ticable
FROM TO DIAMETER THICLiNKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 105 ft 6.25 in. #21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed400
2021-00371 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt. in.
List all applicable Hell permits(i.e.Counm,State. Variance,/ejection,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
❑Geothemlal(Heating/Cooling Supply) El Residential Water Supply(single) tt. ft. in.
❑industrial/Commercial El Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 rc. 20 ft- Bentonite Pumped
Non-Water Supply Well:
rc. rt.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquiter Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Cifapplicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
tt. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,gmin sae,etc.
❑Ceothennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 105 ft. OVER BURDEN
10-15-2021 105 ft- 165 ft• GRANITE
4.Date Well(s)Completed: Well iD#
ft. ft.
5a.Well Location: ft. ft.
Amanda Wilson ft. ft.
Facility/Owner Name Facility ID#(if applicable)
Sheehan Road Fletcher, NC 28732 rt. He 1 I
Phvsical Address,City,and Zip 21.REMARKS
BUNCOMBE 9653972245000
Countv Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one tat/long is sufficient)
N w
10/21-2021
Signature ofCertift WeII Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary Br signing this form,I hereby certijv that the well(s)was(were)constructed in accordance
With 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy qflhis record has been provided to the well owner.
I/(this is a re pair,./ill 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 stone construction,you can
suhmil one%arm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 165 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For,nultiple wells list all depths il'difjerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 Division of Water Resources,Information Processing Unit,
(ft.)
If water 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
m 13a.Yield
(gp ) 20 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: PILLS Amount: 20 well construction to the county health department of the county where
constructed.
Foram GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013