GW1-2021-01166_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD For Internal Use ONLY.
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATERZONEs
HEATH SAWYERS
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING fortnult7-cased wells OR'LINER if applicable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS AND SON WELL +1 ft- 1 115 ft• 16.25 i" #21 PVC
Company Name 16.'INNER CASING OR TUBING(geothermal closed-too
2020-00345 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well pernuts(i.e.County,Slate,Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) FIResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) '18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 rt. 20 ft. BENTONITE PUMPED
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if'applicable)
'
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquiter Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 115 ft. OVER BURDEN
ft. ft.
4.Date Well 10-16-2020 s)Completed: Well ID#
115 ft- 265 ft' GRANITE
Sa.Well Location: ft. ft. F_
JACKIE HANEY ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) -
47 MAG SLUDER ROAD LEICESTER, NC 28748 ft. ft.ft. ft. rt
Phvsical Address,City,and Zip 21..RENtARK5
BUNCOMBE 972200948.E
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one latllong is sufficient) ��N W lh/6 " 01-25-2021
Signature of Certified Well Contract Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this Jorn,I hereby certify that the well(,)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or END copy of this record has been provided to the well owner.
l/this is a repair,fill out known well construction information and explain the nature o/the
repair under-:21 rentarks section or on the hack o/'Ihis fora. 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 h jection or non-wafer supply wells ONLY with the sane construction,you can
suhntit one lirrnt. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hor multiple wells list all depuhs ifdi fereni(example-3 c@r 200'and 2 c@r/00') construction to the following:
10.Static water level below top of casing: 50 (ft.) Division of Water Resources,Information Processing Unit,
//haler 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 AIR 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
m 5 Method of test: RIG 24c.For Water Supply&Injection Wells:
13a.field(gp ) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 30 well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources ` Revised August 2013