GW1-2022-05930_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:
Derrick Heath Sawyers `FRO ATERZONE3 DESCRIPTION
Well Contractor Name ft. ft.
2436-A ft.
NC Well Contractor Certification Number *15.OUTER'CASING for multi-cased A�ell f s)OR LINER i'a licable,
FROM I TO DIAMETER THICKNESS I MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 50 ft 6.25 '" #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
2017-00334 FROM TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. '"'
List all applicable well permits(i.e.County,State,Variance,It jection,etc.)
ft. ft. in.
3.Well Use(check well use): t7.-SCREEN'
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Coolin Supply) l7Residential Water Supply(single) ft. ft. in.
� � g PPY) PPY( g )
❑Industrial/Commercial ❑Residential Water Supply(shared) -18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDiGRAVEL PACK if applicable)
.
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery []Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
�20.DRILLING LOG attach additional sheets if necessary),
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock tyiie,grain sim etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)J 0 ft- 50 ft. OVER BURDEN
05-11-2022 50 ft- 705 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft.
Ty Crawford ft. ft.
�3 �`��'
Facility/Owner Name Facility ID#(if applicable)
ft. ft. 2
White Owl Dr., Candler ft. rt.
Physical Address,City,and Zip '.21.REMARKS
Buncombe 8687 87 5272
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one latlong is sufficient)
N W ' 05-24-2022
Signature of ertified Well C6mractotq 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 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or F1No 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 01 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 ifnecessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 705 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,rise"+" 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
g RI G 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: 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.
Forrrt GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013