GW1-2022-05924_Well Construction - GW1_20220627

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor information:
Derrick Heath Sawyers FRO ATER TONES DESCRIPTION
Well Contractor Name ft. ft.
ft.2436-A rL
NC Well Contractor Certification Number F5.OUTER CASING(for multi-cased wells)OR LINER(if a Gcab T
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +j It. 167 tt• 16.25 in. 1 #21 PVC
Company Name I6,INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable trell permits(i.e.Count),,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 MATERAAI,
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothennal(Heating/Cooling Supply) E'lResidential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT "
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation r 0 e• 20 rt• Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑AquilerRecharge ❑GroundwaterRemediation 19.SANDIGRAVELPACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwatcr Drainage
ft. ft.
❑Experimental Technology ❑Subsidcnec Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
❑Geothennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 IL 67 ft. OVER BURDEN
4-25-2022 67 rc• 225 rr• GRANITE
4.Date Well(s)Completed: Well ID#
fc. fc.
5a.Well Location:
Dwelling Place Homes '; E� a
�� ;i
��.
Facility/Owner Name Facility lD#(if applicable)
ft. ft.
41 Alaskan Drive Leicester, NC 28748 ft.
Physical Address,City,and Zip 21.REMARKS
tl
Buncombe ,;5:� V 4MX::'' /t
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lac/long is sufficient)
N W 5-23-2022
SignatGrrorCerfified Well Ceintractoof Date
6.is(are)the well(s): OPermanent or ❑Temporary Br signing this form,I hereby certf&that the well(s)was(were)constructed in accordance
With 15A NCAC 02C.0100 or 15.4 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 been provided to the it-ell owner.
ll'dtis is a repair Jill out known well construction infimnaiion and explain the nature of the
repair under#21 remarks section or on the back o/'this,/orm. 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 ofwells constructed: construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-tracer supply ivells ONLY with the same construction,You can
suhtnit on form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple trel/s list all depths ifdf f erent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing. 50 (ft) Division of Water Resources,Information Processing Unit,
{l it 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(gpm) 5 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.
Fori-a GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013