GW1-2022-09451_Well Construction - GW1_20221017

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This lin mt can be used for single or multiple wells
i
I.Well Contractor information:
Kolby Mitchell Sawyers F4.WATER ZONES !
F'RO\I TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased-wells)OR LINER(if, licable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 100 ft- 6.25 #21 PVC
Company Name 16.INNER CASING.OR TUBING(geothermal closed-loop)
2022-00010 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. I.
in.
List all applicable nrll permits(i.e.Counba State. Variance,h jection,etc.) ft. ft. 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) El Residential Water Supply(single) ft. ft. in.
❑Ind Ustria]/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 fc. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑E\gttif'er Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHODft. ft.
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,gnin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 100 ft. OVER BURDEN
9-1-2022 100 rc• 205 rc• GRANITE
4.Date Well(s)Completed: Well iD#
ft. ft.
';a.Well Location:
Maureen Sturgis ft. ft.
Facility/Owner Name Facility iD#(ifapplicable)
ft. ft.
Burney Mtn Rd Fairview 28730 ft. R
Physical Address,City,and Zip 21.REMARKS ;:, _.- - I in•i'
Buncombe 9674952995 -
County Parcel ldentification No.(PIN)
51t.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwelI field,one lat/long is sufficient)
N W 9-21-2022
Signature oRC ft Well Contractor Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary Br signing this form,1 hereby certJv that the well(s)was(were)constructed in accordance
with i5A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo cop),gf1his record has been provided to the well owner.
h"this is a repair.•lill out known well construction ititbrnation and erplain[he nature oflhe
repair tinder#21 renarkcs 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.
ror maluiple injection ar non-water svpph•wells ONLY with the sante construction,you can
'abmit one jan•m. 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
ror multiple n•ells list all depths rfdif rent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
IJ water level is abm,e casing.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 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
13a.Yield m 15 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: 20 well construction to the county heaith�department of the county where
constructed.
I"onao GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013