GW1-2021-06057_Well Construction - GW1_20210809

i
WELL CONSTRUCTI'ON RECORD For Internal use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:.
DERRICK HEATH SAWYERS FROM TER`7,ONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2436-A it. it. I
NC Well Contractor Certification Number 15,OUTER GASINGf foF multi-cased s ells OR(LIIYEB ifa licable`
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS AND SON WELL +1 ft. 70 tt• 5.25 in. #188 Steel
Company Name
16 1NNER CASING OR'TUBING "`eolhermal;closed
Q
2020-00448 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State, Variance,It jection,etc.) ft. ft.. in.
3.Well Use(check well use): �111.SCREEN;Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPIY(single) ft. ft. ini
❑Industrial/Commercial ❑Residential Water Supply(shared) -18.;GROUT.. ,. „i• ,-..
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hTi ation 0 it. 20 tt. BENTONITE PUMPED
Non-Water Supply Well:
ft. it.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation M SANUiGRAVEL PACK="if
❑Aquifer Storage and Recovery ❑Salinity Bairiei FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stortnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
24.1)RILLING LOG attach additionai.'stieets:if,oecets'"' "
[]Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness,soil/rock type,griain size,etc.
❑Geothermal(Heating/Cooling Return) OOther(explain under#21 Remarks) 0 ft. 70 tt. OVER BURDEN .
it. rt:
4.Date Well(s)Completed: 06-14-2021 Well ID#
70 it 145 tt GRANITE
5a.Well Location:
Corey Hudgins ft. it.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Buckeye Cove Rd ft. ,
� .
Physical Address,City,and Zip
21.REAIARX ,' "
Buncombe 9688131852 no`J
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
N N a 06-15-2021
Signature o Certified Well Contra t
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby ce fy that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back ofthis form. 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 oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 145 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiiferent(example-3@200'and 2@I00� construction to the following:
10.Static water level below top of casing. 60 (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 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 Servic'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) M
20 ethod of test:
RIG 24c.For Water Supply&Injection 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 lhealth department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013