GW1-2022-07615_Well Construction - GW1_20220817

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells '.
1.Well Contractor Information: I
Derrick Heath Sawyers 4,lVAfRIiGt1NB , _
FROM To DESCRIPTION
Well Contractor Name
2436-A
NC Well Contractor Certification Numberitlultl-¢'Axed,,
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. 39 rt. 6.25 i #21 PVC
Company Name 16 INNERASII!TG„t1RwtiB1IVGisfhermet eibsed too .;;-, y . _: ... ...
2021-00201 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance.Injection,etc.) in.
3.Well Use(check well use):
TJuS`C' R •,',.
Water.Supply Well: FROM '1'0 DIAMETER, SLOTSIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft. H. in:
❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ft. ft. in:
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM U 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 419 SAND/GRA "1P.AGK ifs U6Sti1e `x, _ _, •j
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
320.°b721L1EnG"1t7 :i1ft+ci["addtttonalsteees]fnecessar� r == _ s='.
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soll/rock type,gmin size,etc.
❑Geothermal(Heatin Cooling Retum) ❑Other(explain under#21 Remarks) 0 ft- 39 ft. OVER BURDEN
6-22-2022 39 ft 265 ft• GRANITE
4.Date Well(s)Completed: Well ID# it. ft.
5a.Well Location: ft. ft. ? f v
Patricia Nicholas ft. ft.
Facility/Owner Name Facility IDN(if applicable) ft. ft. G 1 t 2022
Cole Cove Road Candler, NC 28715 ft. ft
,la'a^� r f^vpoc^ Un>
Physical Address,City,and Zip
Buncombe 8696895827 z1YRMARres,•= s �•r.
County Pared Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one tat/long is sufficient)
N W 6-28-2022
Signature of .ertifted Well Cmnraclo � Date
6.Is(are)the well(s): OPermanent or ❑Temporary
Bp signing this firm,/hereby certiJi•that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C,0200 Nell Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or ©No copy ojthis record has been provided to the well owner.
If this is a repair,Jill out known well construction information and explain the nature o he
repair under#21 remarks section or on the back ofthis 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.
Fur multiple injection or non-water supply wells ONLY with the saute constmction,you can
submit onejorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 265 (ft.) 24a. For All Wells: Submit this,form within 30 days of completion of welt
For multiple wells list all depths dfdi(ferent(emntple-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: + (ft-) Division of Water Resources,Information Processing Unit,
IJwater 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 Cen ter,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 25 well construction to the county health department of the county where
constructed.
6
Form GW-1 North Carolina Department of Environmem and Natural Resources—Division of Water Resources Revised August 2013