GW1-2022-03975_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
Derrick Heath Sawyers 14.WATER ZONES
FROM "1'O DESCRIPTION
Well Contractor Name
ft. ft.
2436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER ifa licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 52 ft 61/8 #188 1 Steel
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2020-00096 FROM TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. I in.
List all applicable well permits(i.e.Counm,State. Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
"later Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ElResidential Water SuPPIY(single) f. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 fL 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
❑Aquifer Test ❑Stonnwater 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- 52 ft. OVER BURDEN
3-11-2022 52 ft- 205 ft• GRANITE
4.Date Well(s)Completed: Well iD#
ft. ft.
5a.Well Location:
John Vourath
Facility/Owner Name Facility ID#(ifapplicable)
441 Flat Creek Road Fairview, NC 28730 ft. PF I V F
Phvsical Address,City,and Zip 21.REMARKS
Buncombe 0616545519 APR 12 2022
Countv Parcel Identification No.(PIN) f-j ;
22.Certifcation:5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: � .. iU `s If i
(if well field,one fat/long is sufficient)
N W War-ILS Q 03-29-2022
Signature of ertified Well Ccntracto Date
6.Is(are)the well(s): R Permanent or ❑Temporary By signing this form,i hereby certfv that the well(s)was(were)constructed in accordance
With 15A NCAC 02C.010t1 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy gfthis record has been provided to the well owner.
this is a repair Jill out known well construction inJbrmation and explain the nature at the
repair alder#21 remarks section or at the hack of this.lorni. 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 injection or non-[rater supph wells ONLY with the satne construction.you can
suhlna one non. 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 4 di#r rent(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,
4 outer level is above casing,use'+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b. For Iniection Wells ONLY: =1n 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) 10 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form 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-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013