GW1-2022-07612_Well Construction - GW1_20220817

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This firm can be used for single or multiple wells
I.Well Contractor Information:
14.WATER ZONES
Derrick Heath Sawyers FROM TO DESCRIPTION
Well Contractor Name
2436-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER ifa licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 138 ft- 16.25 1 in #21 PVC
Company Name 16.INNER CASING OR TUBING ebthermal closed-loop)
2022-00013 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Cowin,State.Variance,Injection,etc.)
in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. it. in•'
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrieation 0 ft. 20 rt. 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 EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stonmwatcr Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 138 tt• OVER BURDEN
6-13-2022 138 ft 205 rt• GRANITE
4.Date Well(s)Completed: Well ID#
tt. ft.
5a.Well Location:
Mark Carver fL ft.
Facility/Owner Name Facility ID#(ifapplicablc)
39 Bridges Cove Road Leicester, NC 28748 ft. rL AU6 i 7 202
Plivsical Address,City,and Zip '21.REMARKS
Buncombe 8780940368
Countv Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one]at/long is sufficient)
N W 8-9-2022
Signature of ertified Well Ccntracto Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy q/this record has been provided to the well owner.
It this is a re pair,fill out known well construction information and explain the nalw•e of the
rcpair under#21 rentarks 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.
Fir multiple injection or nun-water supph•wells ONLY with the sane construction,you can
subunit one.lnrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lfdiftrent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
I/lrater level is above easing,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'.n
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: j
(i.e.auger,rotary,cable,direct push,etc.) j
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) 30 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.
Form 0W-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013