GW1-2021-01499_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 --$4 __- ----_- .....
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. k.
NC Well Contractor Certification Number t5:ODt1 ft:CASiIf .toraiiulii-casetltivetls 01t:t 1NRtt. t s bcabic
FROM TO )IAMF.TF.R TMCKNF.SS I MATERIAL
CLYDE SAWYERS AND SON WELL +1 ft- 100 ft- 6.25 #21 PVC
Company Name
td:1dt'IER C? INf rbRT:UBING, eotllerpiial elos 'Oo
2020-00531 hROaI 10 DIAMETER THICKNESS MATFR1AL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Yariance,Injection,etc.) Ct ft in
3.Well Use(check well use):
tLSCREEN.....;'; =ice--.-..
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal (Heating/Cooling Supply) BResidential Water Supply(sin(single) ft ft in.
❑Industrial/Cornmercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&.AMOUNT
❑hri ation 0 t't. 20 fr. BENTONITE PUMPED
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19 SA+TDIURAT.I!A ``>fa' 'cable �.:-
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
20,-DC{ILL[biG,1<fG.(aftaeli adlilttairtal sileetsaf:�cessa ...--...;.. .. ;.-----
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,solll o k tv k grain size,etc.)
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 ft. 100 k• OVER BURDEN
ft. fr.
4.Date Well 02/04/2021 s)Completed: Well ID#
100 ft• 425 ft• GRANITE
5a.Well Location:
Solesbee Const. Company
Facility/Owner Name Facility ID#(if applicable)
800 N. Luther Rd., Candler 28715
Physical Address,City,and Zip -
Buncombe 8687562053
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certifcation:
(ifwell field,one lat/long is sufficient)
N `E 02-04-2021
Signs ertified Well Contras Date
6.Is(are)the well(s): 2Permanent or ❑Temporary
By signing this fn'm,!lrerehv c Jy that the well(+)was(were)constructed in accordancew th 1 SA NCAC 01C.0100 or!SA NCAC 02C.0100 hell Construction Standards and that a
7.Is this a repair to an existing well: OYes or ❑No copy ofthis 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 ofifty/orm. 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.came construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:425 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferemt(example-3@i200'and 1(a,'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 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(gpm)4 Method of test• RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form.within 30 days ofcompletion of
13b.Disinfection type: Amount: 30 well construction to the county health department of the county where
constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013