GW1-2022-10128_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD For Internal Use ONLY:
-This 16rm can be used for single or multiple wells j
i
I.Well Contractor Information:
Kolby Mitchell Sawyers FROATERZONES DESCRIPTION
Well Contractor Name
ft. ft.
4471-A
NC\Vell Contractor Certification Number 15.OUTER CASING(for multi-cased,wells)TO LINER fa Iicable)
FROM TO DIAMETER ! THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 180 ft- 16.25 I in #21 1 PVC
Company Namc 16.INNER CASING OR TUBING(geothermal closed-loop)
2022-00456 FROM TO DIAMETER THICKNESS MATERIAL
2.NN ell Construction Permit#: ft. ft. in.
l.m all applicable well permits(i.e.Countr.State. hariance,hyeclion,etc.)
in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.'
❑Au'ricultural ❑Municipal/Public
❑Geothermal Heating Cooling Supply) E IResidential Water Supply ft. ft. in.
( � e PP Y) PP Y
❑Industrial/Com FR
mercial ❑Residential Water Supply(shared) GROUT
O\1 I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrieation 0 ft' 20 ft- Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stonmwater Drainage
ft. ft.
❑1=sperinientalTechnology ❑SubsidenccControl
20.DRILLING LOG(attach additional sheets if necessar
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/mck type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 80 ft. OVER BURDEN
10-4-2022 80 ft- 185 ft. GRANITE
4.Date Well(s)Completed: Well ID#
rt. rt.
5a.Well Location: ft. ft.
Hubert Creech rt. ft.
Facility/Owner Name Facility ID#(ifapplicable)
40 Hidden Lake Drive Candler, NC 28715 ft.
Plivsical Address,City.and Zip 21.REMARKS
Buncombe 86941305080000 On
Coumc Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field.one W/long is sufficient)
N W 10-10-2022
Signature of Cenlfi Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary Br signing this Jorm,1 herehr certi/6 that the well(s)was(mere)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or FlNo cant'qf1his record has heen provided to[he well owner.
//ihi.s is a repair,Jill ail known 4e11 construction intorrealhtn and explain the nature glthe
repair under#21 rernarlcs section or on the hack g/'this./brnn. 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.
Fin muhiple injection or non-water.supphv yells ONLY with the sate construction.you can
mbuil nne 161-111. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Fm-multiple wells list all depths it*Ql&ent(exannple-9 a,200'and 2(0100') construction to the following:
I
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
Il uaicr level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.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.rouu'y,cable,direct push,etc.)
Division of Water Resources,lUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
m 13a.Yield(gP ) 10 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
131).Disinfection type: PILLS Amount: 20 well construction to the county heialth department of the county where
constructed.
i
norm(iW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
I :