GW1-2022-05233_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., -
Kolby Mitchell Sawyers FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased welts'OR LINER if a lieable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 160 16.25 in #21 1 PVC
Company Name "16.INNER CASING OR TUBING eotherutat closed-loo
2022-OOOOs((��� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,b jection,etc.)
ft. ft. in.
3.Well Use(check well use): I7:SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE 'THICKNESS MATERIAL
fL m.
❑Agricultural ❑Municipal/Public ft.
t I
❑Geothermal(Heating/Cooling Supply) E IResidential Water Supply(single) ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.CROUT .
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ir. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
`
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery []Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
tt. it.
❑Experimental Technology ❑Subsidence Control
20.DRILLING`LOG(attach additional sheets if necess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soilfrock typ
. rain size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 60 ft. OVER BURDEN
3-15-2022 60 fr 305 ft GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Charles Brandon Hensley
Facility/Owner Name Facility ID#(if applicable) ft. ft.
17 Douglas Dr., Lot 2 mg 6 HE
Physical Address,City,and Zip 21:REMARKS;'.
Buncombe 97004696470000
Jll
County Parcel Identification No.(PIN)
i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification.•
(ifwell field,one IaUlong is sufficient)
NVJ'_L05/03/2022
Signature ofCertifi Well Contractor Date
6.Is(are)the well(s): ❑O 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 Nell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No 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: construction details. You may also attach additional pages if necessary.
For multiple iu jection or non-water supply wells ONLY with the same construction.You can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: 30 (rt.) 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 30 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.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013