GW1-2022-02851_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells RECEIVED
I.Well Contractor Information:
14.WATER ZONES 1
Derrick Heath Sawyers FROM TO DESCRIPTION
Well Conti actor Name ft. ft. (f1i)ir'fti.te�.nPr`,+,..,,,inv,
2436-A rt. ft. DwQia�
NC Well Contractor Certification Number 15,OUTER CASING for multi-cased wells)OR LINER if a ocable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 139 ft• 5.25 #188 Steel
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2021-00134 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt. io•
List all applicable well permits(i.e.Coantt,.State. Variance.Injection,etc.)
ft. fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERAAI.
ft. tt. in.
❑ALricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. it. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 rc• 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑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
ft. ft.
❑6xperimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑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- 39 rc• OVER BURDEN
1-24-2022 39 fc. 105 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. tt.
5a.Well Location:
Terry Ingle
Facility/Owner Namc Facility ID#(if applicable) ft. ft.
10 Inglescott Way Alexander, NC 28701 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Buncombe 9711758792
Countv Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field.one W/long is sufficient)
N w 1-25-2022
Signature of ertified Well Contracto6F Date
6.Is(are)the well(s): 2Permanent or ❑Temporary Br signing this fornn.I hereby cert(v 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 o/This record has been provided to the well owner.
Il'thiv is a repair,fill nut known well consavction information and erplain the nature of the
repair under#21 remarks section or on the hack 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 ifnecessary.
For nndtiple injection or non-water supply wells ONLY with the sane construction.you can
sahmii One form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 105 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For mahiple wells list all depths{'fdi(jerent(example-3 a 200'and 2@l00') construction to the following:
10.Static water level below top of casing: 10 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casuhg.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) Method of test: RIG
24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13h.Disinfection type: PILLS Amount: 25 well construction to the county health department of the county where
constructed. I
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013