GW1-2022-02855_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This tbrm can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers F4:WATERROM 'r0 ZONESDESCRI P FTION
Well Contractor Name ft. ft.
4471-A
NC Well Contractor Certification Number `15.OUTER CASING((for multi-eased Wells):OR LINER(if:a 6eable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 130 ft- 6.25 421 PVC
Company Name °16.INNER CASING OR TUBING `eothermal closed-loo
2021-00562 FROM TO I DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: ft. ft. I in.
List all applicable well permits(i.e.Coun),,State, Variance.Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM .1'O DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) EIResidential Water SuPP1Y(single) f. f. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
n. a.
❑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
❑Aquifer Test ❑Stonttwater Drainage
ft, ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary),,
DGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/mck type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 130 ft OVER BURDEN
2-14-2022 130 ft• 185 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location:
John Kilpatrick ft. ft.
r;:
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
748 Upper Glady Fork Road Candler, NC 28715 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Buncombe 8695233883
Countv Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient)
N W 02/21/2022
Signature ol'CertifilyWell Contractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary Br signing this form,1 hereby certgY 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 ElNo copy q/this record has been provided to the well owner.
I/IN.,i.c a repair.Jill out known well con.struclion infbrrnalion and(Tplain the nature of the
repair under 421 remarks section or on the back ojthis 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 supplv wells ONLY with the same construction.you can
submit one lb-In. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths r/di(jerent(example-3 a)200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 (ft,) Division of Water Resources,Information Processing Unit,
eater 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,
L13a.
ATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
eld(gpm) 1OMethod of test: RIG24c.For Water Supply&Injection WellsAlso submit one copy of this form within 30 days of completion of
sinfection type: PILLS Amount: 20 well construction to the county health department of the county where
constructed.
Foim GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 201_