GW1-2022-05092_Well Construction - GW1_20220526

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.Derrick Heath Sawyers FROM ATERZo DESCRIPTION
Well Contractor Name ,
ft. rt.
2436-A rt. rt.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a 6cable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 122 ft• 6.25 #21 1 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2021-00167 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State.Variance,h jection,etc.)
ft. ft, in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal Heating/Cooling Supply) EIResidential Water Supply ft. ft. in.
( b PPY) PPY
❑Industrial/Commercial ❑Residential Water Supply 18.GROUT
pp y(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft. 20 rt• Bentonite Pumped
Non-Water Supply Well:
ft. rt.
❑Mohitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. rt.
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets it necessary)
❑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• 122 ft. OVER BURDEN
4-21-2022 122 ft- 645 ft. GRANITE
4.Date Well(s)Completed: Well lD#
rc. rt.
5a.Well Location: ft. ft.
R&S Investments ft. ft. , )
Facility/Owner Name Facility ID#(ifapplicable) ft ft.
115 Indian Paintbrush Lane Alexander, NC 28701 rt. rt. Y2 6 zor
Physical Address,City,and Zip 21.REMARKS
Buncombe 9721165008 ,
County Parcel Identification No. PIN
,b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one ladlong is sufficient)
N W 4-26-2022
Signature ofCertified Well C6utracto6f Date
6.Is(are)the well(s): OPermanent or ❑Temporary ev signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 iVell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has peen provided to the well owner.
1/7his is it repair,fill out known well construction information and explain the nature of(he
repair under#21 rentarks section or on the back ofthisfa•ttt, 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: construction details. You may also attach additional pages if necessary.
For multiple injection or nor-crater supply wells ONLY with the saute construction,ynu can
submit o efarm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 645 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple n•ells list all depths t,'/'dt,'(Jerent(exautple-3@200'and 2 cr 100') construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
1j'n•ater 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(gym) Methodoftest:
20 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: 35 well construction to the county health department of the county where
constructed.
Forfar GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013