GW1-2022-07629_Well Construction - GW1_20220817

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers FROM ATI:R. NES DESCRIPTION
Well Contractor Name ft. ft.
4471-A
NC Well Contractor Certification Number 15::UU1IR.CASING'.for:iiuttrcased>wells OR-LiNER. f;a heablc ....
FROM TO DIAMETER THICKNESS I MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 r[. 57 r[. 6.25 i" #21 PVC
Company Name A$JN "¢other"ia1°C#osed-16o'" _; __
2021—OO((��QV34 FROM '10 DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. 1"
List all applicable nr11 permits(i.e.County,State,Variance,Injection,etc.)
ft. ft, in.
3.Well Use(check well use): f7 SCREEN
Water Supply Well: FRODI TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
tt. ft. in.
❑Agricultural ❑Municipal/Public
in.
le
❑Geothermal (Heating/Cooling Supply) OResidential Water Supply(sing
)
❑Industrial/Commercial ❑Residential Water Supply(shared) IK'GROI3T "' .......
FROM TO MATERIAL FMPLACFMF.NT METHOD&AMOUNT
❑bTi ation 0 ft' 20 f[• Bentonite Pumped
Non-Water Supply Well:
rt. tt.
❑Monitoring ❑Recovery
Injection Well: It. ff
ble
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL f'AGK;If.a' 'Ca ...
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stomlwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20:-DRTi iAN 'LO,G at(t additional shears 3falecessacv=:,.,,
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color hardness,soil/rmk tv a gmin size,etc.
❑Geothermal Hearin Coolie Return ❑Other(explain under#21 Remarks) 0 ft- 57 ft. OVER BURDEN
7-6-2022 57 a, 405 ft. GRANITE
4.Date Well(s)Completed: Well ft. ft.
59.Well Location: ft. ft.
John McDermott ft. ft. t,Z. a 9 ,
Facility/Owner Name Facility ID#(ifapplicable)
- ft. f[, y ry
2072
Fig Tree Lane, Asheville ft. ft. -
Physical Address,City,and Zip 3� I:;
21 REMARKS" ... � iSt).::�a..
Buncombe 966551066900000 D%A1a
County Parcel Identification No.(P1N)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification
(ifwe0 field,one ladlong is sufficient) •
N WC 07/21/2022
Signature ofCcitifiiMell Contractor Date
6.is(are)the well(s): (OPermanent or ❑Temporary
By signing this,form,1 herehr certify'!hut the well(s)was mere)constructed in acrmrdanre
ivith 15A NCAC 02C.0100 or 15A NCAC 02C.0200 fl,ll Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No copy ofthis record has been provided to the well owner.
ffthis is a repair.fill out known Hell construction information and explain the nature of the
repair under 921 remarks section or on the hack 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
S.Number of wells constructed: 1 construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths it different(example-3(pj200'and 2(a'100') construction to the following:
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
If abler 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 this form within 30 days of completion of well
12.Well.construction method: constriction 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 lCenter,Raleigh,NC 27699-1636
24c.For Water Supply&Injection Wells:
13a.Yield(gpm)4 Method of test: RIG 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-1 North Carolina Department of Environment and Natural Resources—Division of Watet'Resources Revised August 2013