GW1-2022-09467_Well Construction - GW1_20221017

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers FRONT TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
NC Well Contractor Certification Number 15 C)ciT.Eft GA6tb G for_inulii eaeerf cveils.dlx'LAN if-fr ]idalrte`< ._..._. ,------
FRONT TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 54 ft• 6.25 � '" #21 1 Pvc
Company Name fKiNNERCASr(IVG,OR;T,uii NG&Who i•niArdo"4-tau
NC1011077FRONT 1'O DIAMETER THICKNESS NIA'I'NRIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Yap-lance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): f7.,SREElit.,:i
Water Supply Well: FROM TO DIAMETER I SLOT SIZE' I THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Publie
❑Geothermal(Heating/Cooling/Coolin Supply) BResidential Water Supply(single) ft. ft. in.
� g g PpY) PPY g
❑Industrial/Commercial ❑Residential Water Supply(shared)
FRONT TO MATERIAL EMPLACEMENT METHOD&AMOINT
❑Trri ation 0 ft- 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft, ft.
❑Aquifer Recharge ❑GroundwaterRemediation <19�;5YDIGRAEG'PAUI�.da
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stomiwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
201fR1L11NG'X tlG atfaeh addititiialsheetsicessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiVrock tv a gmin size,de.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 54 ft. OVER BURDEN
7-26-2022 54 ff• 705 ft. GRANITE
4.Date Weil(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft.
Costa Carolina Lane
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1468 Bear Creek, Leicester -
ft. ft.
Physical Address,City,and Zip
..2...>12R�4TAR---
Buncombe 97111339380000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N w C. 07/28/2022
Signature ofCc ifilywell Contractor Date
6.is(are)the well(s): RPermauent or ❑Temporary By signing this form,1 herebv certify that the well(s)was(were)constructed in accordance
ivith ISA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No copy of this record has been provided to the well owner:
If this is a repair,fill out knumt well construction information and explain the nature of the
repair under#21 remarks section or on the back e f 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 it jection or non-water supply wells ONLY with the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 705 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd fferent(example-3(aj200'aml 2(a,,100) construction to the following:
10.Static water level below top of casing: 124 (ft-) Division of Water Resources,Information Processing Unit,
Ifwater level is above 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
I
13a.Yield(gpm)
15 Method of test: RIG 24c.For Water Supply&Injection Wells:
,
Also submit one copy of this form I within 30 days of completion of
13b.Disinfection type: PILLS Amount: 35 well construction to the county health department of the county where
constructed. 11
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013