GW1-2022-05086_Well Construction - GW1_20220526

I
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers F_Vyz�TERZoNESR OhI TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
NC Well Contractor Certification Number 15.OUTER CASING for multi cased=, Us OR LINER if a licable
FROM TO DIAMETER THICKNESs MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 60 ft- 6.25 #21 1 PVC
Company Name 16.INNER CASING"OR TUBING""eothermat closed-too
2021-00622 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,L jection,etc.)
rt. ft. in.
3.Well Use(check well use): 17.SCREEN,
FROM TO DIAMETER SLOT B
Water Supply Well: SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling/Coolin Supply) OResidential Water SuPP1Y(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) '18:GROUT.•,." _
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 El Groundwater Remediation 19..SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology El Subsidence Control
�20i DRILLING:UOG attach tidditlonal`sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock typc,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fc. 60 rc. OVER BURDEN
3-15-2022 60 ft• 285 ft• GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location:
Charles Brandon Hensley ft. rD u. l. `
Facility/Owner Name Facility ID#(if applicable) ft. ft. `
Douglas Dr., Lot 3 ft. ft.
Physical Address,City,and Zip
21.REMAitiCS=
Buncombe 97004696140000
County Parcel Identification No.(PIN) a� �j(r,,l i1'�E'r"J
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification•
(if well field,one laUlong is sufficient)
N W1 05/03/2022
Signature of Certifi well Contractor Date
6.Is(are)the well(s): ❑�Permanent or ❑Temporary By 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 KNo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
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 one form. QG SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 285 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@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,
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
50 RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: 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.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013