GW1-2022-07611_Well Construction - GW1_20220817

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This limn can be used for single or multiple wells
I.Well Contractor information:
14.WATER ZONES
Kolby Mitchell Sawyers FROM TO I DESCRIPTION
Well Contractor Name ft. ft.
4471—A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR LiNER(ifa j able)
FROM I TO I DIAMETER I THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 101 rL 6 1/8 1 ';in #188 1 Steel
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop
2021-00561 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
Lin all applicable well permits(i.e.Counts.State.Variance,hnjection.etc.) f[. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well FROM To DIAMETER SLOTSIZF. THICKNESS MATERIAL.
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) EJResidential Water Supply(single) ft. tt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I 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
❑A.luiter Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experinmental Technology ❑Subsidence Control
20.DRILLING LOG attach additionaf sheets if necessary)
[]Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,rrain size,eta
❑Geothermal(i-ieating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rr• 101 rt OVER BURDEN
$-2-2022 101 rr• 165 rr• GRANITE
4.Date Well(s)Completed: Well iD#
5a.Well Location:
Phyliss Cogburn ft. ft. ,
AUG
Paciliiy/Owner Name Facility ID#(ifapplicable) ft. ft.
Duryea Drive Candler, NC 28715 ft. ft. or iv u -;
Physical Address,City,and Zip 21.REMARKS
Buncombe 8684935121
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification
(i(welI field,one lot/long is sufficient)
N W 8-4-2022
Signature ofCerliJ- Well Contractor ! Date
6.Is(are)the well(s): ❑✓Permanent or ❑Temporary By signing this Jornn,I herebv certfv that the well(s)was(were)constructed in accordance
with I5A NCAC 02C.0I00 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo cope gfthis record has been provided to the well owner.
ll this i.s a repair,Jill au/knovrn well consiraction iii rmation and erplain the nature of'Ilie
repair under#2I remarks section or on the back ojthisfiornn. 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.
For nruhiple injection or nan-[rater supply wells ONLY with the same construction,you can
subuil one lbrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 165 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For muhiple wells list a/1 depths((dillerent(example-3 u 200'and 2G/00') construction to the following:
10.Static water level below top of casing:
30 Division of Water Resources,Information Processing Unit,
(ft.)
If enter level is above casing,use"+• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
ROTARY 24a above, also submit a copy of ithis 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,1 Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m 20 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 20 well construction to the county h Ialth department of the county where
constructed.
I
17m m(.iW-I North Carolina Department of Environment and Natural Resources—Division of WaterResources Revised August 2013