GW1-2021-06480_Well Construction - GW1_20211027

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
DERRICK HEATH SAWYERS 14. ''
FRFROMTO DESCRIPTION
Well Contractor Name
2436-A
NC Well Contractor Certification Number 15.OUTER CASING for rrtultl-cased mells ORLINER'if
i lieable i..,
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS AND SON WELL +1 121 16.25 '" #21 PVC
Company Name 16.INNER CASING-OR TIJBING eothermal closet[46apj
2020-00561 FROM TO DIAMETER THICKNESS MATERIAL.
2.Well Construction Permit#: in.
List all applicable well permits(i.e.County,State, Variance,h jection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER: SLOT SIZE THICKNESS MATERIAL.
❑Agricultural ❑Mtmicipal/Public in.
❑Geothermal(Heating/Cooling Supply) E IResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft. 20 tt. BENTONITE PUMPED
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a 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 attach additional sheets if recess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,g rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 21 it OVER BURDEN
ft. rt.
4.Date Well(s) 10-01-2021�Completed: Well ID#
21 ft 205 ft GRANITE
5a.Well Location:
ft. ft.
Warren Gillespie
Facility/Owner Name Facility ID#(if applicable) ft. 21
it. . OCT 9. 7
"
Wiley Acres Dr. ft. ft.
Physical Address,City,and Zip S
Buncombe 9722016929 21.REMARIGS.. r
pVVR Sego
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 `1AM 10-01-2021
Signature o Certified Well Contrariffv
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,1 hereby cethat 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 ofthe
repair under#21 remarks section or on the back ofdris 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 ifnecessary.
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: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(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,
lfwater 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
13a.Yield(gpm)
10 Method of test: RIG 24c.For Water Supply&InjectionlWells:
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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-i North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013