GW1--06709_Well Construction - GW1_20241108

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WELL CONSTRUCTION RECORD For Internal Use ONLY: "
This form can be used for single or multiple wells
1.Well Contractor Information:
Derrick Heath Sawyers F r4 w rsicz s4s za, • h ' g .o.-: • ..z. .. ,
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2436-A ft. ft.
NC Well Contractor Certification Number ,15YOUfttleC'AS[Na(fir ti ultt.cdse fVells)0114f1NERIifltinlealiltr)`r ` z t. as
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 110 ft. 6.25 in. #21 } PVC
Company Name ICM:NER,CASINGTOR-TUBING{gepfhermatiiQsed igop)? . ' .,
2024-00446 FROM TO DIAMETER THICKNESS NIATE:RIAI.
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): 41t7.SCREEtNE ; x;'`_1% ,M;<•. Mitl : °` ` M1.s
Water Supply Well: FROM . TO DIAMETER SLOT SIZE . THICKNESS MATERIAL
Agricultural ❑Municipal/Public ft. ft. in.
•
❑
❑Geothermal(Heating/Cooling Supply) ©Residential Water Supply(single) ft. ft. in.
1CGiROtFf sM c,`ii° 4 . 4=:4<`5°'' y u �i';wI
❑IndustriaUCommercial ❑Residential Water Supply(shared) FROrst TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Obligation 0 ft' 20 ft• Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ORecovery ft. ft. Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑AquiferRecharge ❑Groundwater Remediation 41914SAND/GR1l,')~L•PACKa(it:alipliiille). ` Ma. ' ``.MONf
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery El Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology El Subsidence Control . ., ,, .
410 diet I1�ditijiGltatlae tidd)bbh' h ets ces esary) . '_,',„r
❑Geothermal(Closed Loop) 0 Tracer FROM TO . DESCRIPTION(color,hardness soil/rock type,grain size.etc.) •
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) 0 ft• 110 f' OVER BURDEN
10-8-2024 110 ft. 285 ft. -•*GRAi ITE
4.Date Well(s)Completed: Well ID# _ r~
ft. ft. `c 1.^-^. .'IL,..t• c r i"-..
5a.Well Location: ft ft. n11 U
LEWIS NICHOLSON ft. ft. , 0 n
2024
Facility/Owner Name Facility ID#(if applicable) ft. ft. I :%:7 ;, ;^;; :3,-
25 WILLS LANE CANDLER, NC 28715 ft. ft. c,,v,, _:, . -
Physical Address,City,and Zip fit:REMARKS .,•'' WOM : e't " RIM ^S•. k
Buncombe 9608509082 WELL WAS SELF CERTIFIED
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: 1
(if well field,one lat/long is sufficient) p I
N �, �,I `• 10-15-2024
Signature of citified Well Contractor/• Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this firm,I hereby certify that the well(s)was(were)constructed in accordance
with 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 under#21 r•enrarlo.section or on the back of this Arm 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: 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: 285 (ft.) 24a. For All Wells: Submit this l form within 30 days of completion of well
For multiple wells list all depths if different(example-3 a 00'and 24100') construction to the following:
10.Static water level below top of casing: 20 (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.c.auger,rotary,cable,direct push,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
) 1 00 RIG 24c.For Water Supply&Injection Wells: •
(gpm)
Yield Method of test:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 28 well construction to the county heal.h department of the county where
constructed.
Forts GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013