GW1-2021-03585_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Heath Sawyers 14.'WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2436-A
NC Well Contractor Certification Number 15.OUTER-CASING.for multi-cased wells ORLINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 74 ft- 16.25 in- 1 #21 1 PVC
Company Name 16.INNER CASING OR TUBING eothermal'closed-loo
2021-00230 FROM TO DIAMETER' THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicahle Ieell permits(Le.Counl,State,Variance,Infection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER iSLOTSIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
❑lrri 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 if applicable)
FROM TO MATERIAL; EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
R. fr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional"'sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 r`' 74 r`' OVER BURDEN
7-8-2021 74 f` 185 f` GRANITE
4.Date Well(s)Completed: Well[D# ft. ft.
5a.Well Location:
BRANDON KING
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft.
16 CABIN COVE ROAD LEICESTER, NC 28748 rt.
,t.Pt s
Phvsical Address,City,and Zip 21.REMARKS
BUNCOMBE 97006588290000 w1 Jet„�s'�r3�
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if*well field,one lat/long is sufficient)
N `I 2 7-15-2021
Signature ofCertifie Well C 'actor Date
6.is(are)the well(s): ©Permanent or ❑Temporary By signing this form,i hereby certify that'the well(s)was(here)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 01C.0100 IVell 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.
If dtis is a repair fill out known uve//construction information and explain the nature of the '
repair under 1/remarks section or on the back gfthis farm. 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.
bbr nuilople injection or non-iratersupply rreAs ONLY with the same construction,you can
submit one fbrm. SUBMITTAL iNSTUCTiONS
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Por turdtiple nre/Ls list all depths tfdtfjerem(example-3 ct 100'and 1@100') construction to the following:
10.Static water level below top of casing: 50 (ft) Division of Water Resources,Information Processing Unit,
l/water level is above casing,use—" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For injection Wells ONLY: in addition to sending the form to the address in
ROTARY 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) 7 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this forml within 30 days of completion of
13b.Disinfection type: Amount: 20 well construction to the county heal Ith'department of the county where
constructed. ,
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013