GW1-2023-00665_Well Construction - GW1_20230105

WELL CONSTRUCTION.RECORD For hi
[emal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers x4 TO
FROM TO DESCRIPTION
Well Contractor Name ft. ft. 1
4471-A ft. ft.
NC Well Contractor Certification Number
15,.t)UCE#2CA5ilAt:.for.;matu,caseawelis tiltitfNER.tis 1[catite`r .r.. G.. :
FROM TO DIAMETER THICKNESS t\fATF.RiAi.
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 1101 ft- 6.25 t , in- #21 PVC
Company Name BIER Cl+$IRfx-t)R I UBINO, 4athenata!ttRs¢ IpU V t
2022-00367 BROaI 10 DIAMETER THICKNESS NIATERIAI.
2.Well Construction Permit#: ft. ft. ': ' in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. [t. in,
3.Well Use(check well use): lEf..SCREIet .,.. E
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/CoolingSupply) EIResidential Water Supply(sin(single) in,
❑lndustrialICommercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT MF.TH01)&AMOUNTS
❑hTi ation 0 ft. 20 ft• Bent6nite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation _
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery El Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control
-- 11-i1It1LL�l�f 'IOf;:aftaeh¢aiidl ">.ats6eeftafreeessaty'� ------.'. �`-�" t�`�:.>
❑Geothermal(Closed Loop) ❑Tracer FROnI TO DESCRIPTION color,hardness,soil/rmk ri e rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) 0 ft. 101 ft. OVER BURDEN
12-28-2022 101 ft 185 ft• GRANITE
4.Date Well(s)Completed: Well ID# t
5a.Well Location:
Armando Martinez ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
54 Green Acres Ur,'[
Physical Address,City,and Zip '-REMARIfS:° -, ..... ` -
Buncombe 97010704260000 This well is self certify
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 `,1t 12/30/2022
Signature ofCcitifilyw0l Contractor Date
6.is(are)the well(s): l7Permanent Or ❑T¢mpOYary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
ivith 15A 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 known well construction information and explain the nature of the
repair tinder 921 remark section or on the back ofthis farm. 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 ifneccssary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. 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
For multiple wells list all depths ij'dijferent(example-3(d200'and 2(a.100) construction to the following:
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection 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)
7 Method of test: RIG 24c.For Water Supply&Injection Wells
PILLS Also submit one copy of this farm within 30 days of completion of
13b.Disinfection type. Amount 35 well construction to the county iea th department of the county where
constructed.
Fortes GW-1 North Carolina Department of Environment and Natural Resources—Division of"Vater�Reisources Revised August 2013