GW1-2022-02856_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD For Internal Use ONLY: } F�
This form can be used for single or multiple wells w i�
1.Well Contractor Information:
Kolby Mitchell Sawyers FRO WA ZONES TO DESCRIPTION f
Well Contractor Name ft. ft. �he''�.t%v " Wit
4471-A
NC Well Contractor Certification Number 1.5.`OUTER CASING for multi-cased wells OR LiNER if'a licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 67 ft 16.25 1 in• #21 PVC
Company Name 16.INNER CASING OR,TUBING. eothelmal:closed-loo'
2021-00642 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: e. tt. 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 SLOT S17.E THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 20 ft. Benton:ite 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
t[. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if recess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) 0 n. 67 ft. OVER BURDEN
12-20-2021 67 ft 385 f[ GRANITE
4.Date Well(s)Completed: Well ID#
tt. ft.
5a.Well Location:
Robert Polk ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
103 Little Bee Tree Lane ft.
Physical Address,City,and Zip 21.REMARKS
Buncombe 978070800400000
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 W 12/20/2021
Signature of Certifi Well Contractor of Date
6.Is(are)the we6(s): OPermanent or ❑Temporary By signing this form,i hereby certili,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 web: ❑Yes or E)No copy of this record has been provided to the well owner.
If this is a repair,full out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of thisform. 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. pC SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 385 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(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,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i
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 m 4 Method of test: RIG 24c.For Water Supply&injection Wells:
(gp ) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 35 well construction to the county health department of the county where
constructed.
i
Forst GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013