GW1-2021-01184_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:
DERRICK HEATH SAWYERS FROM TO DESCR,PT�..�..,...
lON
Well Contractor Name
2436-A
NC Well Contractor Certification Number 15.OUTERCTASLGor wltl•cp ,,, LINR
O DIAMR TIESa" cable
FROM MATERIAL
CLYDE SAWYERS AND SON WELL +1 ft. 72 ft. 6.25 in. 1 #21 1 PVC
Company Name
I6.INNER CASTING OR TUBING "ieht" al lased-loo"
2020-00452 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt. in.
List all applicable well permits(i.e.County,Stare,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use):
--
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft• ft. in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. 15L in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18'GROUT
FROM 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/GRAVEL PACK ifa' licable
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach edditioua sbeets if necess '''
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sofUrock rain size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1 0 ft 2 tf OVER BURDEN
ft. ft.
4.Date Well 03-01-2021 s)Completed: Well ID#
72 f` 205 ft. GRANITE
5a.Well Location: ft. ft.
R & S INVESTMENTS
Facility/Owner Name Facility ID#(if applicable)
Indian Paintbrush Ln., Lot #9 rt.
Physical Address,City,and Zip , ;_
<2I:REMARKS`' F:. ..t
Buncombe 9721178197
County Parcel Identification No.(PIN) r.82r. h
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
N ,l o%s a. 03-03-2021
Signature o Cemfied Well ConM t
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this form,1 hereby ce �that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 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 remarks 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: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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 24aabove, 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 m 20 Method of test: RIG 24c.For Water Supply&Injection Wells:
(gp ) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount• 25 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