GW1-2023-00660_Well Construction - GW1_20230105

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This lorni can be used for single or multiple wells
I.Well Contractor Information:
14.`WATER ZONES
Kolby Mitchell Sawyers FROM TO DF,SCRIP7'ION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-casedii-ells)OR LINER(if a licable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 144 ft- 16.25 #21 PVC
Company Name 16.INNER CASING OR TUBING eottiermtd closed400 `
2022-00450 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits•(i.e.County,State.Variance,injection,etc.) ft. ft. in.
3.Well Use(check well use): 17 SCREEN f.
Water Supply Well: FROM TO DIAMETER SLOTSILE THICKNESS MATERIAL
ft. ft.❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ft. ft. in•
❑Industrial/Commercial ❑Residential Water Supply(shared) t8.'GROUT'
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
[]Monitoring ❑Recovery
Injection Well: ft. ft.
❑AquiferRecharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Agtiifel•Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwatcr Drainage
ft. ft.
❑Experimental 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 Return) ❑Other(explain tinder#21 Remarks) 0 ft. 44 ft. OVER BURDEN
10-17-2022 44 ft• 245 tt• GRANITE
4.Date Well(s)Completed: =Well ID#
ft. ft.
5a.Well Location: ft. ft. _
Shanika Deitz ft. fr. X,L.� 4,t I V'i
Facility/Owner Name Facility iD#(ifapplicable)
68 Teague Road Leicester, NC 28748 ft. ft.
Physical Address,City,and Zip 21.REMARKS nfon'n u^❑ Prr? ^ts f r
Buncombe 87938799310000 -r'V1 Q 3Ov
Countv Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(i well field,one fat/long is sufficient)f
N W
11/10/2022
Signature of'Certifity Well Contractor Dale
6.is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
ivith l SA NCAC 02C.0I00 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or i]No copy of this record has been provided to[he'well owner.
If1his•is it repair•,,fll out known well construction information and nrplain the nature ofthe
repair corder#21 remarks section or on the back o/'this form. 23.Site diagram or additional well details:
You may use the back of this pag6'to provide additional well site details or well
i.
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For nnrhiple injection at,non-wctler supply wells ONLY with the sane construction,you can
s„bild/one/bran. SUBMITTAL INSTUCTIONS
9,Total well depth below land surface: 245 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple hells list all depths ifdrftrent(example-3 a?00'and 2@100') construction to the following:
I 10.Static water level below top of casing: 30 (ft.) Division of Water Resour,ces,Information Processing Unit,
jf waicr(erel 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,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(gpm) 5 Method oftest: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this fa6l within 30 days of completion of
I3b.Disinfection type: Amount: 25 well construction to the county health department of the county where
constructed.
Fonii(i W-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013