GW1-2021-06478_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
„14.aWA7'ER`ZONES...^2Y'��r.�xixi
DERRICK HEATH SAWYERS FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2436-A it. tt.
NC Well Contractor Certification Number 15:`.OUTER;GASNG"for'multl eaetl}Wk[Is;OR:I INER,if k 'Iick67e <
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS AND SON WELL +1 ft• 42 ft• 6.25 '" #21 PVC
Company Name
&INNI R,CASING.ORTUBING "catherma►c)bsed-ton yu,,,, ,,,
2021-00102 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: it. tt. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use):
17SGREEN�
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft.❑Agricultural ❑Mtmicipal/Public in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(sin(single) ft. ft. in.
❑h1dUStriaV 18.GROUTCOmmerCial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft. 20 ft. BENTONITE PUMPED
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation '19.SAND/GRAVEL"PACK tfa 1161116
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHODft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
n20.'DRILLING LOG attkch additiuiial=shiets.if uecess
❑Geothermal(Closed Loop) ❑Tracer FROM( TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 42 e• OVER BURDEN
ft. ft.
4.Date Well 08-27-2021 s)Completed: Well 1D#
42 ft 205 tt GRANITE
5a.Well Location: ft. tt.
Robert Kiss
Facility/Owner Name Facility ID#(if applicable) ft. ft. 2 ,11
25 Connie Davis Rd. ft. Unit
Physical Address,City,and Zip r r StI1�,
2I:REM ARKS
.,..`=......
Buncombe 8685502375
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one ladlong is sufficient)
N W 08-30-2021
Signature o Cemfied Well Contra t
6.Is(are)the well(s): ❑�Permanent or ❑Temporary By signing this form,!herebl,ce i i,that the well(s)was(were)constructed in accordance
with 15A NCAC 02C A/00 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or END copy of this 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 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 at-non-water supply wells ONLY with the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ifderent(example-3@200'and 2@100') 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 Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm)
20 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: 20 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