GW1-2021-06061_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
i
1.Well Contractor Information:
K 14.WATER ZONES
Olby Sawyers
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
NC Well Contractor Certification Number 15.,OUTER CASING for multi-cased,wells OIt,LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 196 rt. 6.25 '" #21 1 PVC
Company Name 16INNER CASING OR TUBING- eothermal closed-loo _ -
2020-00437 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt. in.
List all applicable well permits(i.e.County,State,Variance,h jeetion,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
f[. ft. in•
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(sin(single) ft. ft. in•
❑Industrial/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:
❑Aquifer Recharge ❑Groundwater Remediation 19.°SAND/GRAVEL PACK ifa licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING-LOG attaeb additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiVrock type,grain size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) 0 I'L 96 ft. OVER BURDEN
06/21/2021 96 ft- 465 ft- GRANITE
4.Date Well(s)Completed: Well ID#
ft. tt. v
5a.Well Location: ft. ft.
Aero Way LLC ft. rt.
Facility/Owner Name Facility 1D#(if applicable) ft. ft.
Thistle Lane ft. Ift rratjon Proce.ssing tJflft
Physical Address,City,and Zip 21.REMARKS
Buncombe 9675731045
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certific 'on:
(if well field,one Iat/long is sufficient)
N N 06-28-2021
ignature of e i tp
Well Contract i ! Date
6.Is(are)the well(s): 2Permanent or ❑Temporary
By signing this form,/hereby—
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: ❑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 ofthe
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
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 one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 465 (it•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 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 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
k
13a.Yield 4 Method of test: RIG 24c.For Water Supply&Injection Wells:
(gpm) 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-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013