GW1-2022-02853_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Derrick Heath Sawyers FROM TO DESCRIPTION
Well Contractor Name
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2436-A
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a 6cable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 180 ft. �61/4 I in. #21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2021-00161 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. R. in.
List all applicable well permits(i.e.County,State. Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATF.RIA11
in.
❑Acricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling,Supply) lResidential Water SuPP1Y(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft' 80 rut. 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 EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stotmwater Drainage
ft. ft.
❑Experinmental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary),
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,graia size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 80 ft• OVER BURDEN
2-11-2022 80 ft 145 ft GRANITE
4.Date Well(s)Completed: Well TD#
ft. ft.
5a.Well Location:
R&S Investments LLC
Facility/Owner Name Facility ID#(if applicable)
Rolling Hills of French Broad Lot 35 Alexander rut. ft.
Physical Address,City,and Zip 21.REMARKS
Buncombe 9721168023 -
County Parcel Identification No.(PIN) ;iK+"'•j
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5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: '.� -`
(if well field,one Wilong is sufficient)
N W 2-14-2022
SignatureofCertified WellCcnlraclo Dale
6.Is(are)the well(s): ❑e Permanent or ❑Temporary By signing this form,I hereby certfv 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 END copj•ofthis record has been provided to the well owner.
11*Ihis is a repair.fill out known well construction in/bnnation and e�rplain the nature glthe
repair under 421 renmrks section or on the back o/'this fibrin. 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 br non-water supple wells ONLY with the scone construction,you can
SUBMITTAL INSTUCTIONS
submit Otte moan.
9.Total well depth below land surface: 145 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i/different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
If eater level is above easing,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:
20 RIG 24c.For Water Supply&Injection Wells:
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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 countywhere
constructed.
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Forur GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013