GW1-2022-05231_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.WATER ZONES
Derrick Heath Sawyers FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
2436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased,wells)OR LiNER(if a licable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 95 ft. 6.25 #21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-too
2021-00389 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft in.
List all applicable null permits(i.e.County,State. Variance,hytection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIn11
ft. ft. in.
❑A,gricultural ❑Municipal/Public
❑Geothetnial Heating Cooling Supply) E(Residential Water Supply ft. ft. in.
( � b PP Y) PP Y
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 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
❑Aquiter Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwatcr Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiltrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 95 ft. OVER BURDEN
4-1-2022 95 ft 325 ft GRANITE
4.Date Well(s)Completed: Well iD#
ft. ft.
ft. ft. PR y. rt p -r c,
,a.Well Location: -
Newfound Creek Enterprise fc. ft. mAy2 6 2M
Facility/Owner Name Facility ID#(ifapplicable)
26 Pilgrims Path Alexander, NC 28701
Physical Address,City,and Zip 21.REMARKS Ii iiirl'.*pa'-: '' r:
Buncombe 9711196273
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
N W 4-18-2022
Signature of Air,ed Well Contracto Date
6.Is(arc)the well(s): ❑O Permanent or ❑Temporary Br 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 Melt Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo cop),gl'this record has been provided to the well owner.
If1hi.s is a repair,Jill out knouru well construction ln%rnation and arplain the nature ofthe
repair under#21 rentarks section a•on the back o/'this•forn. 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 ifnecessary.
Far multiple injection or non-water supply wells ONLY with the saute construction,you can
submit one.%a•m. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 325 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple irells list all depths ifdiOcrent(exantple-3 u 200'and 2 ct 100') construction to the following:
10.Static water level below top of casing: 50 (ft) Division of Water Resources,Information Processing Unit,
1/water leret is above casing,use'•+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b. For Injection 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 6 Method of test: RIG 24c.For Water Supply&Injection Wells:
(gP ) Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: PILLS Amount: 30 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