GW1-2022-07622_Well Construction - GW1_20220817

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor information:
KDlby Mitchell Sawyers 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft. p
4471-A ft. ft. I
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased'wells)OR LINER(if.a Beable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 t[. 160 16.25 1 #21 PVC
Company Name 16.iNNER CASING OR TUBING eothermal closed400
2018-00496 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
L isl all applicable n ell permits(i.e.County,State. Variance,11yection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER' SLOTSIZE THICKNESS MATERIAL
ft. ft, in..
❑Agricultural ❑Municipal/Public
❑Gcothennal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
El Irrigation 0 fc. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑AquiterRecharge ❑GroundwaterRemediation I9.SAND/GRAVEL PACK ifa licable
LA
❑Aqu FROM iter Storage and Recovery ❑Salinity Barrier ft. TO ft.
MATERIAL EMP CEMENTMETHOD
❑Aquifer Test ❑StonnwatcrDrainage 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.)
❑Gcothennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 160 it OVER BURDEN
7-18-2022 160 ft- 325 ft. GRANITE
4.Date Well(s)Completed: Well TD#
fc. ft.
5a.Well Location:
Bradford Rogers _
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. F F.
131 Ridge Road Candler, NC 28715 it. it.
Physical Address,City,and Zip 21.REMARKS
Buncombe
County Parcel Identification No.(PIN) J{VO/LOG ^
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N `I 7-20-2022
Signature ofCertii Well Contractor I Date
6.Is(are)the well(s): 2Permanent or ❑Temporary Br signing this form,/herebv certify that Ithe well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ZNo cope gfthis record has been provided to the well owner.
l/(thi.s is u repair Jill out known well construction inJnrmalion and explain the nature oflhe
repair mrder#21 remarks section or on the back o/'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: 1 construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-wider svpphv wells ONLY with the sante construction,You can
subnul one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 325 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiftrent(example-3G200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 Division of Water Resources,Information Processing Unit,
ll,,atcr/eve/is above casing,use"+• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b. For Infection Wells ONLY: Inl 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.) 'I
Division of Water Resources,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: 35 well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013