HomeMy WebLinkAboutGW1-2021-00149_Well Construction - GW1_20211213 WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers F4.WATER ZONES PTA..
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471—A
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a lieable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 it. 119 it 6.25 i" #21 PVC
Company Name ;:16.INNER CASING OR TUBING eothermal closed-loo"
2021-00113 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,h jection,etc.)
ft. ft, in.
3.Well Use check well use): 17.SCREENb-
Water Supply Well: FROM TO DIAMETER. SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. ini
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 it. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring DRecovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
El Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
DRILLING LOG attach additional sheets ifnecess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type, rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 119 ft. OVER BURDEN
12-03-2021 119 it• 245 ft- GRANITE
4.Date Well(s)Completed: Well iD#
ft. ft.
5a.Well Location:
CMH Homes
Facility/Owner Name Facility ID#(if applicable)
ft. ft. Ut L 1 3
Jupiter Rd., Lot 2, Weaverville ft.
Physical Address,City,and Zip 21.REMARKS,`,
Buncombe 973550564100000
County Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one]at/long is sufficient)
N N, 12/06/2021
Signature ofCeri fr Well Contractor 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 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 1he
repair under#21 remarks section or on the back ofthisform, 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 oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 245 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiiferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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
13a.Yield(gpm)
10 Method oftest:
RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this foiTn within 30 days of completion of
13b.Disinfection type: PILLS Amount: 35 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