GW1-2022-02854_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.
Kolby Mitchell Sawyers ES
FROMER 'to
FROM 1'O DESCRIPTION
Well Contractor Name
4471-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER(if'k ticable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 115 rc• 6.25 ! #21 1 PVC
Company Name 16.INNER CASING OR,TUBING "eothermal closed-loop)
2021-00508 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Couno,,State. Variance,/ejection,etc.) ft. ft. in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 IL 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. tt.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if aiiiiiWablO
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20 DRILLINGLOG(attach additionatsheets'if necessar'),�.
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 fc, 115 tc OVER BURDEN
2-14-2022 115 rc• 225 rc• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
H&S PROPERTIES
Facility/Owner Name Facility ID#(if applicable) ft. ft.
138 OAK MTN LEICESTER, NC 28748 ft. ft.
Physical Address,City,and Zip 21.REMARKS ff
BUNCOMBE 879031041000000
County Parcel Identification No.(PIN) r,d tIX LW
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: c7c7��7
01'well field,one hat/long is sufficient)
02/15/2022
N W
Signature of Certift Well Contractor Date
6.is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,l hereby certify 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 ONO copy of 1his record has been provided to the well owner.
/l this is a repair,fill out known well construction iglbrrrralion and explain the nature of the
repair raider 42/remarks section or on the back ojthis 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 if necessary.
Far multiple injection or non-water supply wells ONLY with the same construction,you can
submit one loon. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple}veils list all depths i/'di(Jerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 20 Division of Water Resources,Information Processing Unit,
It irate/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) 50 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