GW1-2022-02862_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD For Internal Use ONLY: � -� �i��
This form can be used for single or multiple wells S `w{z�� Ff E D
1.Well Contractor Information:
14.WATER ZONES --
Kolby Mitchell Sawyers FROM TO DESCRIPTION
Well Contractor Name ft. ft. to#�, B .0.1�fII�Sw 1P('�Unit
4471-A ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER a lieable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 2a ft 6.25 '" #21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
2018-00473 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. DIAMETER
List all applicable well permits(i.e.Count)),State. Variance,Injection,etc.)
f[. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FnoM TO DIAMETER SLOTSILF] THICKNESS MATERIAL
in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) El Residential Water SuPPIY(single) ft. fL in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft' 20 ft, 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
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑TIacer FROM I TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 24 ft- OVER BURDEN
6-4-2020 24 ft 605 ft- GRANITE
4.Date Well(s)Completed: Well iD#
ft. ft.
5a.Well Location:
Igor Korolchuk
Facility/Owner Name Facility ID#(if applicable)
68 Squires Lane Candler, NC 28715 ft. ft•
Physical Address,City,and Zip 21.REMARKS
Buncombe 9608642153
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
N w Y7a
6-20-2021
Signature ofCer ifi Well Contractor Dale
6.Is(are)the well(s): 2Permanent or ❑Temporary Br signing this form,I hereby certify that the well(s)was(were)constructed in accordance
With 15A NCAC 02C.0I00 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy gf1his record has been provided to,ithe well owner.
It this is a repair.fill out known well construction infornmtion and explain the nature of the
repair under#21 remarks section or on the back of this 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 ifnecessary.
For multiple iryec•tion or non-water suppty wells ONLY with the same construction,you can
suhnrit one form. SUBMITTAL 1NSTUCTIONS
9.Total well depth below land surface: 605 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i/'Qferent(example-3@200'and 2@100') construction to the following:
150 Division of Water Resources,information Processing Unit,
10.Static water level below top of casing:
I/stater 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
l
13a.Yield(gpm) 6 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
136.Disinfection type: PILLS Amount 35 well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013