GW1-2022-07625_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
Kolby Mitchell Sawyers FROM TO DESCRIPTION
\Nell Contractor Name
ft. rt.
4471-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells)OR LINER if a Mable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 21 ft- 6 1/8 j in. 1 #188 1 Steel
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2021-00210 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
Ow all applicable aril permits(i.e.County,State, Variance,Injection.etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN i
Water Supply Well: FROM 7.0 DIAMETER SLOTSIZF. 'THICKNESS MATERIAL
ft. ft. in•'
❑Agricultural ❑Municipal/Public
ft. f. in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water SuPPIY(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irr; ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑N1on itori ng ❑Recovery
Injection Well:
❑AquilerRecharge ❑GroundwaterRemediation 19.SAND/GRAVEL PAC K ifa licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquiter Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquiter Test ❑Stonmwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional Sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiltrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fc' 21 fc• OVER BURDEN
6-22-2022 21 fc• 145 fc• GRANITE
4.Date Well(s)Completed: WeII ID#
ft. ft.
5a.Well Location:
Jeffrey Dodd
facility/0"tier Name Facility ID#(if applicable) ft. ft.
2537 Lower Flat Creek Road Hendersonville, NC 28711 e u
Phy>ical Address,City,and Zip 21.REMARKS
Buncombe 062522601300000
C•OIInIV Parcel Identification No.(PIN)
51).Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
nfwell field•one lat/long is sufficient)
N M 7-21-2022
Signature ofCertifi Well Contractor X
6.Is(are)the well(s): 2Permanent or ❑Temporary Br signing this Jorin,I herebv certq[ that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0I00 or 15A NCAC 02C.0200 Well Cqy Fyltrcti!.4tpnll rd that a
7.Is this a repair to an existing well: ❑Yes or ElNo copygf1his record has been provided to the well owner. hh''��JJ ({
l/ihis is a repair.Jill oul known well construc(ion in/brntalion and evtlain the nature of the
repair under#2l remarks section or on the hack of,this firm. 23.Site diagram or additional well details: Ift iamif&ic-n Pr �ue'1h51Rg Ur1;t
You may use the back of this page to provide additionabb� ails or well
8.Number of wells constructed: 1 construction details. You may also!attach additional pages ifnecessary.
Fur tnuhildc injection or non-voter sllpphr wells ONLY with the scone construction,you can
cuhmil one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 145 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welly list a/1 depths tfdihterent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 40 Division of Water Resources,Information Processing Unit,
U„ater level is above easing,use + 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.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
m 13a.Yield
(gP ) 12 Method of test: RIG 24c.For Water Supply&Injection Wells:
i
Also submit one copy of this form within 30 days of completion of
131).Disinfection type: PILLS Amount: 20 well construction to the county hi alth department of the county where
constructed.
Pori G W-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013