GW1-2023-02760_Well Construction - GW1_20230417

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers 14rWATlsR7ANES
FROM TO DESCRIPTION
Well Contractor Name
4471-A
51-1
NC Well Contractor Certification Number . 6TRR CASLNG fora rurii cased wetly:O1tL13VER'if a licatiie
FROM TO DTAMF.TF.R THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 «• 101 ft. 6.25 in. #21 PVC
Company Name t6;I NNER`CASfNGQRTVBINQ `gpther»ieYsloseli=too` _...
2022-00367 FROM DIAMWIT.R THICKNESS MATERIAL
Z.Well Construction Permit#: in.
List all applicable welt 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 I MATERIAL
❑Agricultural ❑Mulnicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft In.
T. `.<...
❑Industrial/Commercial ❑Residential Water Supply(shared) 3ti GROI3 . `
FROM TO MATERIAL FM PLACEMENT METHOD&AMOUNT
❑Irri ation 0 et. 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation 19:SANDlGRAVEh'PACK d'a ""'cable .. =_'
❑Aquifer Storage and Recovery ❑Salinity Battier
FROM
ft. TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stomiwater Drainage
ft. ft.
❑Experimental Technology El Subsidence Control 20�DRICIA GLOG.art ebadditionalsheets�itnecessa "`
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION COIDr.hardness,soil/rack tv a xmin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 101 ft• OVER BURDEN
4.Date Well(s)Completed: 12-28-2022Well ID# 101 ft• 185 ft. GRANITE
ft. ft.
5a.Well Location: R. it. r
Armando Martinez
ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) APR ^3
ft. ft. 1 1 0 L
54 Green Acres ft. ft. ;,r ,� ,
Physical Address,City,and Zip S a
21 RENtARKS e . -• v. o
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 `,tt 12/30/2022
Signature of Certifi ell Contractor Date
6.Is(are)the w•ell(s): OPermanent or ❑Temporary By signing this form,1 herehv certify that the well(s)was(were)comstrueted in accordance
with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 it ell Comstruc•tion Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo copy of this record has been provided to the well owner.
If this is a repair•fill out knoun well construction information and explain the mature of the
repair under 921 remark-section or on the back of this 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: 1 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: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(cxamp/c-3@200'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'uater 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
13a.Yield(gpm) 7 Method of test• RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 35 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013