GW1-2023-01950_Well Construction - GW1_20230227

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
W,
Kolby Mitchell Sawyers FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
NC Well Contractor Certification Number
0?%1 10_ DIAMETER I THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft.
1100 ft 6.25 [ '. #21 PVC
Company Name CWTASWaIrlif'T
202 ft.2-00385 FROM TO DIAMETER
R in. THICKNESS MATERIAL
2.Well Construction Permit#-.
List all applicable is-ell permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS_LMATERIAL
ft. it. in.
DAgricultural DMunicipal/Public in.
0Gcothermal(Heating/Cooling Supply) ®Residential Water Supply(single)
01ndustrial/Cornmercial EIResidential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Ells-rigation 0et. 20 ft- Bentonite Pumped
Non-Water Supply Well:
DMortitoring ORecovery
Injection Well: ft. ft.
ElAquifer Recharge 0 Groun dwater Remediation tAW"
OAquifer Storage and RecoverySalinity Banier FROM ft. TO ft. MATERIAL EMPLACEMENT METHOD
El
DAquifer Test 0 Stormwater Drainage ft. ft. I
OExperimental Technology El Subsidence Control S120,11,A)MEM, I WRO
oGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
[]Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks L 0 100 ft OVER BURDEN
12-21-2022 100 ft 305 ft GRANITE
4.Date Wells)Completed: —Well ID# ft. ft.
5a.Well Location: ft. ft.
Brandon Hensley ft. ft. FLU 2 5. (0-023
Facility/Owner Name Facility ID#(if applicable)
1193 Bear Creek Leicester, NC 28748 ft. ft.
Physical Address,City,and Zip
Buncombe 97113099750000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwetl field,one lat/long is sufficient) 22.Certification: i
N W tz, 0 . C 2-9-2023
Signature ofCcitifliMell CouLctor 'I Date
6.Is(are)the well(s): 21'ermanent or OTemporary By signing this form,I hereby certify that the sell(s)was(were)constructed in accordance
with 15A NC_4C 02C.0100 or 15A NCAC 022C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or E]No copy of this record has been provided to the well oi477cr.
If this is a repair,fill out known well construction information and explain the nature of the i
repair under#21 remarks section or on the back of this jbrm. 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: 1 construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-water supply wells ONLY with the sante construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface.- 305 —(ft-) 24a. For All Wells-: Submit this form within 30 days of completion of well
For multiple wells list all depths iJ'efiJJerent(example-3@200'and 2(a.1 00� construction to the following:
10.Static water level below top of casing: 20 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 Injection Wells ONLY: ist'addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ROTARY 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) 20 Method of test- RIG 24c.For Water Supply&Injection►JWeIIs:
Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: PILLS Amount: 30 well construction to the county heaflth!department of the county where
constructed.
FormGW-1 North Carolina Department ofEuvironment.and Natural Resources-Division of Water R eso&ces Revised August 2013