GW1-2022-05923_Well Construction - GW1_20220627

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
Kolby Mitchell Sawyers FRO ATER to DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number '`15.OUTER CASING for multi-cased wells)OR LINER(if a Gcable)
FROM TO DIAMETER THICKNESS 11fATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 8o ft- 6.25 #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed400)
2021-00453 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable urll permits(i.e.Count),,State.Variance,hrjection,etc.)
in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL.
ft. ft.❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water SuPP]Y(single) ft ft. in.
18.
❑industrial/Commercial ❑Residentia;Water Supply(shared) FROMROUT TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft' 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring El Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer•Test ❑Stonnwatcr Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)-,
❑Geothermal(Closed Loop) ❑Tracer FRO31 TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) 0 ft. 80 rt. OVER BURDEN
5-18-2022 80 fc• 185 ft• GRANITE
4.Date Well(s)Completed: Well
ft. ft.
,a.Well Location: ft. ft. A u
o 'r•ice„ -,w..a •j 44+� .'�
Donald McKenzie Jr ft. ft.
Facility/Owner Name Facility iD#(ifapplicable) ft. ft.
19 Fisher Knoll Lane Alexander, NC 28701 ft. Urih
Phvsical Address,City,and Zip 21.REMARKS
Buncombe 971464953000000
Comity Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification-
(if well field,one lot/long is sufficient) •
N W 06/03/2022
Signature orCertifitYWell Contractor Date
6.is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,1 hereby certJv 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 ONo copy gf1his record has heen provided to the well owner.
ll'this is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 rentarls section or on the back g1'this•fbnwn, 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-n•ater snpph•wells OA'LY with the saune construction,you can
snhnnt one Innn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nu liple hells list all depths ff di&rent(example-3 u 200'and 2@1001 construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
I/water level is ahove 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.anger,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 15 Method of test- RIG 24c.For Water Supply&Injection i Wells
:
(gP ) 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.
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013