GW1-2022-02857_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells P.
,e_L'Lt E::D:]
1.Well Contractor Information:
i 14.WAT:ER,,ZONES .. .._.._ .r... =.''
Derrick Heath Sawyers FROM TO DESCRIPTION
Well Contractor Name ft. ft. $ P=_a_
2436-A ft. ft. G1'E' IBOG
NC Well Contractor Certification Number 15.`OUTER GASING"For uialh cased`ZyelL4 OR LINER it a "licable ,
FROM I TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 41 ft- 6.25 1 #21 PVC
Company Name
16 MEWCASING.OR T ING4ieothei vial closed loo
2017-00405 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: tt. tt. in.
List all applicable well permits(i.e.County,State, Variance,byeetion,etc.)
ft. fL in.
3.Well Use(check well use): 47.SCREM*k4z . ..
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS d MATERIAL
ft. ft. in:
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) EIResidential Water SuPP1Y(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 15.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20 rt. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation -.19.SAND/GRAVEL PACK:if a licable ;,
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
•.20 DRILLING LOG attach additional sheets if'necess"
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiltrock type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 1 ft. OVER BURDEN
1-22-2019 41 ft 205 ft GRANITE
4.Date Well(s)Completed: Well ID#
ft. rt.
5a.Well Location:
Andrew Green
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
398 Old Leicester Rd
Physical Address,City,and Zip "21.REMARKS.
Buncombe 9720542951
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)
01-22-2019
S�gnatu of en�G-ed�Well CointNra`cto Date
6.Is(are)the well(s): 2Permanent or ❑Temporary er signing this form,1 hereby certifv 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 E]No copy of(his record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 remarks section or on the back ofthis_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.
For multiple injection or non-water supply wells ONLY with the same construction,von can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface• 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d!/ferent(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,
Ifwater 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 m 20 Method of test: RIG 24c.For Water Supply&Injection Wells:
(gP ) Also submit one copy of this fore within 30 days of completion of
13b.Disinfection type. PILLS Amount: 25 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013