GW1-2022-10134_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This loan can be used for single or multiple wells l
I.Well Contractor Information:
14.WATER ZONES l f
Kolby Mitchell Sawyers FROM TO DESCRIPTION
Wdl Contractor Name ft. ft.
4471-A ft. ft. I
\'( \Nell Cantractur Certification Number 15.OUTER CASING(tor multi-cased wells)OR LINER if a Gcable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 170 it 6.25 ii" 1 #21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-too
2022-00185 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt. in.
l.isl all applicable Nell permits(i.e.Caanly,.S'tate.Variance.lnjection,etc.)
ft. fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAI,
ft. ft. in.
❑A126Cultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. ft. in
Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrieation 0 ft. 20 rt. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquiter Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
DI-speriniental Technology ❑Subsidence Control
20.DRILLING LOG attach'additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(ex lain under#21 Remarks) 0 ft' 70 ft OVER BURDEN
11-4-2022 70 ft 165 ft GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
Sa.Well Location:
Daven Embler ft. it.
Facility/Owner Nmnc Facility ID#(ifapplicable) ft. ft. NOV1 O 2022
49 Chadwick Wade Drive Asheville, NC 28803 ft. ft.
11hs,ical Address,City,and Zip 21.REMARKS
Buncombe 973200334600000
Cnunty Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
if well field.one tat/long is sufficient)
11-8-2022
N W
Signalure of Certifi Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this Jorm,I hereby certi(b that the well(s)was(were)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 EINo copy gfthic record has heen provided to the wet(owner.
//11i.c is a repair.Jill ow known well construction infimnalion and explain the nature ofthe
repair under#2l remurks section or on the back o)'this 1brm. 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: construction details. You may also attach additional pages ifnecessary.
lL,r u«dliple injection or non-wWer supple wel/s ONLY with the saute construction.you can
srrhmit rue 1nrur. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 165 (ft.) 24a. For All Wells: Submit this,form within 30 days of completion of well
/vu nnrbiple uV1ls list all depths ij'di/Jcrent(example-3@200'and 2@400') construction to the following:
10.Static water level below top of casing: 20 (ft•) Division of Water Resources,Information Processing Unit,
/l nrner lerel 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:
1 ix.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) 20 Method of test: RIG 24c.For Water Supply&Injection Wells:
t
Also submit one copy of this form within 30 daysofcomplction of
131).Disinfection type: PILLS Amount: 20 well construction to the county health department of the county where
constructed. f
l"'I m OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013