GW1-2021-00148_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:
>14.WATER ZONES:. .'°„
Kolby Mitchell Sawyers "FRO„ 'to DESCRIPTION
Well Contractor Name
4471—A ft.
NC Well Contractor Certification Number 15.OUTER CASING;for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 60 fc 6.25 1n #21 1 PVC
Company Name '16.INNER CASING OR TUBING ei tl erma]closed4ori
2021-00114 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 47.SCREEN..
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. tt. in
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. tt. in•,
01ndustrial/Commercial ❑Residential Water Supply(shared) ;IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20 ft- Bentorite Pumped
Non-Water Supply Well:
rt. rt.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. rt.
❑Experimental Technology ❑Subsidence Control
30.DRILLING LOG attach additional sheets if necess
❑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 f[' 60 ft. OVER BURDEN
12-03-2021 60 ft- 145 ft. GRANITE
4.Date Well(s)Completed: Well ID#
rt. ft.
5a.Well Location: ft. rt.
CMH Homes ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
Jupiter Rd., Lot 3, Weaverville LIEC 13 2t
Physical Address,City,and Zip 21 REMARKS„ >i
Buncombe 973550632800000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if welt field,one]at/long is sufficient) •
N W 12/06/2021
Signature ofCenifilyWell Contractor Dale
6.Is(are)the well(s): ❑✓Permanent or ❑Temporary By signing this form,1 hereby certift that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or I5A NCAC 01C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONO cony o/this record has been provided to the well owner.
If 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 ofthis 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: 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: 145 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii&rent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 ([t•) 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 Iniection 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
l2.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(gym)
20 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.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013