GW1-2021-00164_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor information:
14.WATER ZONES
Derrick Heath Sawyers FROM TO DESCRIPTION
Well Contractor Name
2436-A
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased`wells)OR LINER(if a licable)
FROM I TO DIAMETER I THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 172 ft' 6.25 i #21 Pvc
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)....
2020-00255 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. '"'
list all applicable❑ell permits(i.e.Counh•.State. Variance./ejection.etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATFRIAI.
in.
❑Agricultural ❑Municipal/Public
❑Geothemtal(Heating/Cooling Supply) El Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft. 20 e. 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 EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiltrock type,grain size,etc.
❑Geothenmal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 72 rt. OVER BURDEN
10-15-2021 72 rt• 425 rr• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location:
Michaela Gossett ft, ft. n 1
Facility/Owner Name Facility ID#(if applicable) ft. R.
40 Hampton Road Leicester, NC 28748 ft.
Phvsical Address,City,and Zip 21.REMARKS
Buncombe 9701319795
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 w klar.ILS 11-3-2021
Signature of-Certified Well C(Tn(racto6F Date
6.Is(are)the well(s): 2 Permanent or ❑Temporary Br signing this form,I hereby certJi+that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.I1200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or FlNo copy gfthis record has heen provided la the well owner.
If this is a repair.Jill out k`nou•n well construction in/brination and explain the nature of the
repair under 421 remarks section or on the back ojdus 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 ifnecessary.
For multiple injection or non-tracer supply wells ONLY with the sane construction,You can
SUBMITTAL INSTUCTIONS
submit one form.
9.Total well depth below land surface: 425 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple a ells list all depths ifdi(jcrent(example-3@100'and 2@100') construction to the following:
10.Static water level below top of casing: 80 Division of Water Resources,Information Processing Unit,
(ft.)
If water level is above eash{g,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 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) Method of test:
RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this forte within 30 days of completion of
13h.Disinfection type: PILLS Amount: 35 well construction to the county health department of the county where
constructed.
Potato GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013