GW1-2021-06062_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Kolby Sawyers s
FROM TO DESCRIPTION
Well Contractor Name
4471-A
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR'LINER if a licabie'<
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 103 ft- 6.25 in. #21 PVC
Company Name 16.INNER CASING OR TUBING" eothermal closed4oti
2021-00132 FROM TO DIAMETER THICKNESS ry 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 SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single)
18.GROUT
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM TOX MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft. Benton'ite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.i SAND/GRAVEL PACK-if a lichble ..
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additiorial'sheets iE necess
❑Geothennal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,gnin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 103 ft• OVER BURDEN
06/25/2021 103 ft• 505 ft• GRANITE
4.Date Well(s)Completed: Well 1D#
ft. ft.
5a.Well Location:
CMH Homes
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1069 Sharon Ridge ft. ft. AU
Physical Address,City,and Zip
�.ZI:`REMARKS.�
Buncombe 968528189400000
Inforr'..3WI,
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certitic 'on:
(if well field,one lat/long is sufficient)
N w 06-25-2021
ignatureofte?NV Well Contract I Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,I hereby certifv 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: ❑Yes or ElNo copy,ofthis record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature offhe
repair under#11 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: 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. C C SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 505 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(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
1
13a.Yield(gpm) Method 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: 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