GW1-2022-02850_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells �_
I.Well Contractor Information: Z�®C 4g
14.WATER ZONES
Derrick Heath Sawyers FROM DESCRIPTTION FEB
ft.
Well Contractor Name ft. .,
2436-A ft. ft. *, • : .:,.;.;, n
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased4611s)OR LINER(if app fieabh`)
FROM I TO I DIAMETER I THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 1105 ft• 5.25 I '" #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2021-00530 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. i"•
List all applicable well permits(i.e.Countp.State. Variance,/ejection,etc.) ft. fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM rp DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public
❑Geothermal(Heatinbg/Cooling Supply) El Residential Water SuPPIY(single) ft ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) t8.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifcr TCSt ❑Stornwatcr Drainage
ft. ft.
❑Lxperimcntal Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft- 105 ft. OVER BURDEN
1-4-2022 105 ft 305 ft• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
,a.Well Location:
CMH Homes
Facility/Owner Name Facility ID#(if applicable)
25 HG Buckner Meadows Leicester, NC 28743
Phvsical Address,City,and Zip 21.REMARKS
Buncombe 971098985300000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
1-6-2022
N W
Signale of ertified Well Ccntracto Dale
ur
6.Is(are)the well(s): RPermanent or ❑Temporary Br signing this form,1 hereby certi&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 cony gfthis record has been provided to the well owner.
If this is a repair,till out known well construction inlimnation and eiplain the nature ol'the
repair under#21 remarks section or on the back of this,%nn. 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 ifnecessary.
For multiple injection or non-water.cupp(v wells ONLY with the same construction,you can
submit one to, 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 medtiple wells list all depths i(di(lerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 40 (ft) Division of Water Resources,Information Processing Unit,
1/wester 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
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) 5 Method of test: RIG
24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13h.Disinfection type. PILLS Amount: 30 well construction to the county health department of the county where
constructed.
Power GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013