GW1-2022-09460_Well Construction - GW1_20221017

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This firm can be used for single or multiple wells
I.Well Contractor information:
Kolby Mitchell Sawyers FR WATER ZONES
OAI 'r0 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 a Gcabte)
FROM TO DIAMETLR THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 f1. 44 rut• 6.25 I '" #21 1 PVC
Company Name 16,INNER CASING OR TUBING(geothermal closed-loop)
2020-00562 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State. Variance,11yection,etc.) ft. ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM ro DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. fL in,
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft, Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring El Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicablc
FROM TO MATERIAL EMPLACEMENT METHOD
[]Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experinmental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain sae,etc.)
❑Geothertnal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 44 ft. OVER BURDEN
9-8-2022 44 rc• 905 rc• GRANITE
4.Date Well(s)Completed: Well ID#
rut. rut.
,a.Well Location:
Igor Mustsevoy
Facility/Owner Name Facility ID#(if applicable)
Cedar Mtn Road Fairview, NC 28803 ft. ft.
Phvsical Address,City,and Zip 21.REMARKS
Buncombe 9666895983
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one hat/long is sufficient)
N W 09/28/2022
Signature ofCert.fi Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary BY signing this form,I herebP certifv that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Mell Consuvction Standards and that a
7.Is this a repair to an existing well: ❑Yes or FINo copy ofthis record has been provided to the well owner.
ll'lhi.s is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back oJ'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 if necessary.
For nnbiple hijection or non-water supply wells ONLY with the sane construction,you can
'.sahmil one Jbr,n. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 905 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple n•ells list all depths iI*QJerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 80 (ft.) Division of Water Resources,Information Processing Unit,
//'water level is ahore 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: 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(gym) 2 Method of test: RIG
24c.For Water Supply&Injection Wells:
Also submit one copy of this form'within 30 days of completion of
13b.Disinfection type: PILLS Amount: 35 well construction to the county healthldepartment of the county where
constructed.
Form,GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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