GW1-2022-10135_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This florin can he used for single or multiple wells
I.Well Contractor Information:
14.WATER ZONES
Kolby Mitchell Sawyers FROM TO DESCRIPTION
Well Contractor Name ft. ft. f
4471-A it. ft.
NC WrII Contractor Certification Number 15.OUTERCASING formulti-cased wells)OR LINER if a ticable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 fc. 1136 ft• 16.25 j 1O #21 PVC
Company Name �+ 16.INNER CASING OR TUBING eothecmal closed-loop)
2021-001 OV FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: tt. tt, in.
List all applicable well permits(i.e.County,State. Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.'SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE-1-THICKNESS MATERIA11
❑Agricultural ❑Municipal/Public
❑Geothenmal(Heating/Cooling Supply) ElResidential Water SuPP1Y(single) ft. tt. in.
R
❑Industrial/Commercial ❑Residential Water Supply(shared) F GROUT i
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft' 20 ft- Bentonite Pumped
Non-Water Supply Well:
❑Monitoring El Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable),
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwatcr Drainage
ft. ft.
❑Fxperimental Technology ❑Subsidence Control
20.DRILLING LOG I attach additional sheets if.necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 R• 136 ft- OVER BURDEN
9-16-2022 136 ft, 136 ft, GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location: ft. ft.
Larry Cook ft. rt.
Facility/Owner Name Facility ID#(if applicable) NOV 459 Ox Creek Rd Weaverville NC 28787 t►. ft,
Physical Address,City,and Zip 21.REMARKS ' f1f1
Buncombe 97619970090000
Countv Parcel Identification No.(PIN)
i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient) Kah ) (. "�= 11-8-2022
N W
Signature orCertifi Well Contractor i Date
6.Is(are)the well(s): ©Permanent or ❑Temporary Br signing this Jorm,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consutretion Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy gf1his record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 rentarks section or on the back o/'this Joan. 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.
Far uudtiple injection or non-trater.supph•wells ONLY with the same construction,you can
n SUBMITTAL INSTUCTIONS
stthina ne form.
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths t/di(jerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Restiurces,Information Processing Unit,
Il urger level is above easing,use'+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection Wells ONLY:I In addition to sending the form to the address in
ROTARY 24a above, also submit a copy of f 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 Injecfion Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service C i enter,Raleigh,NC 27699-1636
24c.For Water Supply&Injection
13a.Yield(gym) 20 Method of test: RIG Wells:Also submit one copy of this form within 30 days of completion of
I3b.Disinfection type: PILLS Amount: 20 well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013