GW1-2022-05105_Well Construction - GW1_20220526

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor informattiion:
Derrick Heath Sawyers FROwATERZ ONES DESCRIPTION
Well Contractor Name ft. ft.
2436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased;wells).? LINER(if a' cable).
FROM TO DIAMETER. THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft' 36 ft• 6.25 #21 PVC
Company Name 16.INNER CASING TUBING(geothermal closed-too.
2021-00402 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt. in.
List all applicable well permits(i.e.Counp;State.Variance,injection,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) El Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 GROUT ,fir
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑ln-igation 0- ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑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 ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20:DRILLING`LOG'(at[ach additional sheets if necessa
❑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' 36 ft. OVER BURDEN
2-18-2022 36 ft- 205 ft. GRANITE
4.Date Well(s)Completed: Well ID# ft. ft. r ra 9 �"---
Imo',"'•
5a.Well Location: ft. ft. " '
Tara Conley ��
Facility/Owner Name Facility iD#(if applicable) ft F, eF;A
. it. .sr;c:l S°�`r`42 i R
102 Saddle Ridge Drive Alexander, NC 28701
Physical Address,City,and Zip 21:REMARKS
Buncombe 971289008500000
Countv Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one laUlong is sufficient)
N w 4-14-2022
Signature of Certified Well Contraclo Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereb1 certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 01C.0100 Well Constntction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy gfthis record has been provided to the well owner.
lfthis is it repair,jilt out known we//construction information and arplain the nature ofthe
repair under#21 remarks section or on the back o/'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 saute construction,Yon can
submit once form. 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 multiple wells list all depths ifdijferent(example-3@200'and 1@100� construction to the following:
10.Static water level below top of casing: 50 (ft,) Division of Water Resources,Information Processing Unit,
1j'warer level is above caring,use'•+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection 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) 10 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• 20 well construction to the county health department of the county where
constructed.
Firm GW-I - North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013