GW1-2022-02860_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD For Internal Use ONLY: �.� ,,This form can be used for single or multiple wells v. y°R V
I.Well Contractor Information:
DERRICK HEATH SAWYERS 1RWATERZONE3 _
FROM TO DESCRIPTION
Well Contractor Name ft. ft. I. jf7`ft'Sf' r1ur:•1 nfII+.W "wtsi� Unii
2436-A ft. '•
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER(if a livable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS AND SON WELL +1 f[. 47 ft- 16 5/8 i in. 1 #188 1 Steel
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2021-00308 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: f[. ft. in.
List all applicable well permits(i.e.Counrv,State. Variance,hyection,etc.) rt. rt. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER. SLOTSIZE THICKNESS MATERIAL
ft. ft. in;
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. ft. in.
❑In(ILlstrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑]n'i*ation 0 ft. 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 ❑Stormwatcr Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 47 ft. OVER BURDEN
ft. ft.
4.Date Well 12-23-2021 s)Completed: Well ID#
47 f[• 465 ft• GRANITE
5a.Well Location:
Lonisa McAdams
Facility/Owner Name Facility ID#(ifappliceble) f[. ft.
Cane Creek Road Fletcher, NC 28732
Phvsical Address,City,and Zip 21.REMARKS
Buncombe 966335471600000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
0I'well field.one W/long is sufficient)
N N 1-6-2022
Signature o Certified Well Contra t
6.Is(are)the well(s): OPermanent or ❑Temporary Br signing this,jbnn,l hereby ce i 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 ONo cope gf1hi.s record has been provided tollhe well owner.
l/this is a repair,Jill out known well construction in/itrmation and explain the nanere ofthe
repair under 921 remarks section or on the back o/7his 1brm. 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_ater.supph-wells ONLY with the same construction,vrm can
snhonit atu-forhn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 465 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i/'di(jcrent(example-3@200'and 2 ct 100') construction to the following:
10.Static water level below top of casing: 60 (ft,) Division of Water Resources,Information Processing Unit,
it ater level it above caving,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 AIR 24aabove, 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) 1 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this farm within 30 days of completion of
13b.Disinfection type: PILLS Amount: 30 well construction to the county health department of the county where
constructed. 1
Form G W-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013