GW1-2022-03974_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.WATER ZONES
Derrick Heath Sawyers FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
2436-A
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if`a Geable)
FROM I TO I DIAMETER I THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 199 ft. 6.25 r in. 1 #21 1 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2O2 -00292 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft• fL in.
List all applicable well permits(i.e.Count),,State. Variance.Injection,etc.)
in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAI,
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) IS GROUT ;
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
El 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 ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothenmal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 99 ft. OVER BURDEN
1-25-2022 99 ft 205 ft• GRANITE
4.Date Well(s)Completed: _ Well iD#
ft. ft.
5a.Well Location:
Dale Morgan ft. ft. r�
Facility/Owner Name Facility iD#(if applicable) ft. ft.
1245 Newfound Road Leicester, NC 28748 it rtAPH 2 2022
Phvsical Address,City,and Zip 21.REMARKS
Buncombe 86897383170000
tidt'i4"t3"N I I]llY�l
County Parcel Identification No.(PIN) cY:v,liSSRf
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
N 03-28-2022
SignatuACerfi fled W el I Contracto Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this form,I hereby ceu'tyf that the well(s)was(were)constructed in accordance
With 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consruction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy ofthi.s record has been provided to the well owner.
It this is a repair,fill out known well construction inJartnation and explain the nalw e of the
repair under 421 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
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection w non-water,supph-wells ONLY with the saute construction,van can
submit one 16on. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For muhiple wells list all depths it"different(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 hater 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,
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
13h.Disinfection type: PILLS Amount: 25 well construction to the county health department of the county where
constructed. i
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013