GW1-2021-00167_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 FROM DESCRIPTION
Well Contractor Name
4471-A r`
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a'Gcable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 106 ft- 6.25 #21 PVC
Company Namc 16.INNER CASING OR TUBING(geothermal closed-too
2021-00133 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: it. tt. in.
List all applicable well permits(i.e.Counq,.State. Variance,Injection,etc.)
ft. fL in.
3.Well Use(check well use): 117.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE, THICKNESS MATERIA1,
ft. ft. in.
❑Agricultural ❑Municipal.Public
❑Geothemial(Heating/Cooling Supply) EIResidential Water SuPP1Y(single) ft. ft. in•
Cl Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 20 rt. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑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 ❑Stonr(water Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach addi600alsheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gnin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 tt• 106 rt• OVER BURDEN
11-2-2021 106 ft- 305 ft- GRANITE
4.Date Well(s)Completed: Well iD#
rt. rt.
5a.Well Location:
Jeffrey Corn
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Laurel Fork Trail Candler, NC 28715 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Buncombe 8696999526
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
V7A� ) C-JU rr!A: ,ye�= 11-16-2021
N W
Signature of Certifi Well Contractor V Date
6.is(are)the well(s): 21'ermanent or ❑Temporary By signing this form.I herebv certiji 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 FlNo copy of this record has been provided to the well owner.
If this is a repair.fill out known well construction inlorntalion and explain the nature al'the
repair raider#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
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
Fur multiple iryectiun or non-water supplr wells ONLY with the same construction,You can
submit one(arm. 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 i(di(jcrent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 40 (1t,) Division of Water Resources,information Processing Unit,
If water 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 forth 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)
7 Method of test: RIG 24c.For Water Supply&In.iectioIn Wells:
Also submit one copy of this fotTn within 30 days of completion of
13b.Disinfection type: PILLS Amount: 30 well construction to the county health department of the county where
constructed.
Pons G W-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013