GW1-2022-03979_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:
Kolby Mitchell Sawyers FROM REZONES -:. . IPTI. .
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
NC Well Contractor Certification Number 45.OUTER'CAS[NG f6'rmulh casei3%wells°OR'LINER i£a lieable a'
FROM I DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 52 ft- 6.25 #21 PVC
Company Name ',,,A&JNNER CASING OR TUBING""'eo#6erulal`closed:loil' a, ,-,r---
2021-00307 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): t7,SCREENS...
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft.❑Agricultural ❑Municipal/Public in:
❑Geothermal(Heating/Cooling Supply) EIResidential Water SuPPIY(single) ft f[ in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT,,&O,
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation `I9.`SANDIGW7EIi:PACK:if a' licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft, ft.
❑Aquifer Test ❑Stormwater Drainage
tt. tt.
❑Experimental Technology ❑Subsidence Control
20:DRILLING,LOG attach adilrhorial sheets if.oecess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 52 e• OVER BURDEN
e• fL
4.Date Well 2-17-2022 s)Completed: Well ID# 52 185 GRANITE
ft. ft.
5a.Well Location:
Conrad Clark Builders LLC
Facility/Owner Name Facility ID#(if applicable) ft. ft. ° -•
22 Stocksville Rdg APR 12 2021
Physical Address,City,and Zip
21"REMARKS;+ .,�:(,,
Buncombe 9745969120 &-%1WM
County Parcel Identification No.(PIN) vsfti lai d P :OCES? !V IJ1 11
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification•
(if well field,one lat/long is sufficient)
N W 03/01/2022
Signature ofCertilijfwjl Contractor Dale
6.Is(are)the well(s): OPermanent or ❑Temporary 8v signing this form,I hereby cent fv 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 ofthis record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
repair under#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
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit oneform. 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 ifili ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 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 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 m 7 Method of test• RIG 24c.For Water Supply&Injection Wells:
(gp ) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 35 well construction to the county health department of the county where
constructed.
Forth GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013