GW1-2023-00667_Well Construction - GW1_20230105

4
WELL CONSTRUCTION RECORD For hrtemal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers FROM TFR'7TO DESCRIPTION
Well
Well Contractor Name ft. fr.
4471-A
iS,: UTEl2.4iS11+tG forituld:easel#wells.OftLlNEtt:`iGa"'iiea6[e .
NC Well Contractor Certification Number FROM TO I DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 170 ft. 16.25', #21 1 PVC
Company Name 16:ISNER A$JNtx d"08JN 4Gfb rtii4T SMs@tt=tQti
055-2022-0475 FROM 1'O DIAMb l'ER THICKNESS MATERIAL
2.Well Construction Permit#: ft. fr. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): t7.3GRBElV ..• ... .
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/CoolingSupply) ElResidential Water Supply(sin(single)
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIALEMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation :18,ISeSi�IOR€l EL PAZ Ifs da cabl
FRO51 TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stomiwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
=2Q�1]11;11.1.11�ttjl�QG°atfaeb:arrdrtihualsheats:i6nceessar"v`�.� ,..�..�x,-r. «
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillmk type. rain size,etc.)
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 ft' 70 ft OVER BURDEN
12-27-2022 70 ft 165 fr GRANITE
4.Date Wells)Completed: Well ID#
ft. ft.
5a.Well Location:
Conrad Clark Builders LLC ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft, JAN
22 Stocksville Rdg ft. ft. h
Physical Address,City,and Zip ".. _ ...:??.. . ...... ;
Buncombe 9745969120 This well was self ce ifie" '
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 ,It CJ. 12/29/2022
Signature of'Certiflywa Contractor Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,1 herebv certify'thut the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200%ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No copy ofthis 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 021 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
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: 165 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ij'di/ferent(example-3 nil 00'unit 2(al00) construction to the following: I
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 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) 15 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 35 well construction to the county health department of the county where
constructed.
Forrn GW 1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
i
II