GW1-2022-03977_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
DERRICK HEATH SAWYERS 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased vMls)OR LINER(if a licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS AND SON WELL +1 ft. 60 ft 6 1/8 in. 1 #21 1 Pvc
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
2021-00076 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicuhle well permits(i.e.Countil,State. Variance,hyeetion,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN ,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERAA1,
❑Agricultural ❑Municipal/Public ft. ft. in.
[]Geothermal(Heating/Cooling Supply) E IResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 f" BENTONITE PUMPED
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
-injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a lieable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonmwater Drainage
ft, ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiltrack type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 60 ft. OVER BURDEN
f:. ft.
4.Date Well 1-10-2022 s)Completed: Well ID#
60 fL 705 ft. GRANITE
5a.Well Location: ft. ft.
Peter Santora ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Beaverdam Road Asheville, NC 28804 `� �"
fl, ft.
APR
Plivsical Address,City,and Zip 21.REMARKS
Buncombe 975057318500000 _
Cowuv 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)
N N 1-15-2022
Signature o Cerified Well Contra t
6.Is(are)the well(s): ❑�Permanent or ❑Temporary Br signing this for, 1 hereby ce ifv 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 ❑No cop),gf1his record has been provided io the well owner.
If Ihi.s i.s a repair,Jilt out known well construction in1brr»ation and explain the nature of the
repair under#21 remarks section or on the hack ojdus,(orm. 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.
Fur multiple iniretiun or non-water supph-welly ONLY with the saute construction,you can
suhmit ore lbrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 705 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For urultiple we/Is list all depths r/'Qkrent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 160 (ft) Division of Water Resources,Information Processing Unit,
11 itaier 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 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 m 3 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.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013