GW1-2021-01176_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:
KOLBY MITCHELL SAWYERS FR.WATER ZONE$.,
FOM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number
15 OUTER CASING.for multi cased wells OR LINER fbi licabie
FROM TO D4IMETER THICKNESS MATERIAL
CLYDE SAWYERS AND SON WELL +1 ft. 195 ft- 6.25 in. 1 #21 1 PVC
Company Name :16:INNER CAuYG.OR:T,DBING: 4othermalclosed IOq�
2020-00411 FROM TO DIAMETER THICKNESS _ MATERIAL
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): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.FROMROUT..To,
MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20 ft. BENTONITE PUMPED
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GR VVELPACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. fL
❑Experimental Technology ❑Subsidence Control
20 DRILLING 1;OG attach additionst sheets if ttecessa
❑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 rt• 95 ft. OVER BURDEN
ft. ft.
4.Date Well 12-18-20 s)Completed: Well ID#
95 rr• 185 rt• GRANITE
5a.Well Location:
CB Weatherman
Facility/Owner Name Facility ID#(if applicable) ft ft.
395 Old US 1923 HWY, Candler ft. ft.
Physical Address,City,and Zip
21.REMARKS'__��-
Buncombe 869700787000000
County Parcel Identification No.(PIN) Ii��GI1 3�iuSI 7f(;06'fi al,Jg E 711
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(if well field,one lat/long is sufficient)
-82.728745 N 35.536488 W A, 01-21-2021
Signature o erti Twell Cont for Date
6.Is(are)the well(s): ❑✓Permanent or ❑Temporary By signing this form,I herebv certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes 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 remarks section or on the back oj'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 supphy wells ONLY with the same construction,you can
submit oneform. 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 iftli ferent(example-3@200'and 1@100') construction to the following:
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 Iniection 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
13a.Yield(gpm) Method of test: RIG
24c.For Water Supply&In,Iection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 20 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