GW1-2022-03973_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.I`WATER ZONES
Derrick Heath Sawyers FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased+wells)OR LINER{ifa ti able)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 f" 50 ft. 16.25 in. 1 #21 1 PVC
Company Name I6;INNER CASING OR TUBING eothermal closed-loop)
2O2 -OO2HH FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List till applicable well permits(i.e.County State, Variance,Injection,etc.) ft. fL in.
3.Well Use(check well use): 17.'SCREEN
Water Supply Well: FROM TO DIAMETER sLOTSIZE THICKNESS MATERIAL
in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) PJResidential Water SuPP1Y(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ISrGROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 fc. 20 fc. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable ,.
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20..DRILLING LOG(attach additional sheets>if:necessar
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness,soil/rock type,giain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fc' 50 ft OVER BURDEN
1-26-2022 50 fc• 165 fc GRANITE
4.Date Well(s)Completed: Well ID#
ft. rt.
5a.Well Location:
Dale Morgan ft. ft. ,_
II
Facility/Owner Name Facility ID#(ifapplicablc) ft. ft.
1281 Newfound Road Leicester, NC 28748
Physical Address,City,and Zip 21>REMARKS
Buncombe 86897350440000
County Parccl Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(if well field,one lat/long is sufficient)
N Wwar.IL.s03-28-2022
Signature oCCertified Well Cc�ntmctoG7 Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary Br signing this form,I hereby certify 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 END copy gf1his record has been provided it)the well owner.
/)this is a repair.,Jill out known well construction inJbrmalion and explain the nature gl'the
repair under 921 remarks section or on the back o/'thisJonn. 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 nudtiple injection or non-water supply wells ONLY with the same construction,you can
crrhmil one form. 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 multiple wells list all depths it"QJ&ent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
4 nzner level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection 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) 50 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: 25 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
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