GW1-2022-05088_Well Construction - GW1_20220526

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers FROM TO .
RO TO DESCRIPTT ION
Well Contractor Name ft. ft.
4471 A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased4ells)OR LINER"(if a 6cable)-
FROM I TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 83 ft. 6.25 in• #21 PVC
Company Name 16.'INNER.CASING OR TUBING(geothermal closed-too)..
2021-00218 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Counp,,State.Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) E]Residential Water Supply ft. ft. in.
d PP Y) PP Y
❑Industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT.
FRObt TO_ MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri 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 applienble
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 addiNainatsheets'if necessar .-
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) 0 ft. 83 et. OVER BURDEN
4-27-2022 83 fc• 605 fc• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Mark Goode
Facility/Owner Name Facility ID#(if applicable) ft . -
. ft.
70 Propst Road Candler, NC 28715 -
Physical Address,City,and Zip 21:REMARKS
Buncombe 9618159426
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N W 20 05/17/2022
Signature ofCcrtifilyWell Contractor 0 Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the well oivner.
/(this is a repair,fill out known well construction infbrnation and�rplain the nature ofthe
repair a nder#21 remarks section or on the back ofthis forn. 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 sanne construction.You can
submit one fa•tn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 605 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For n u liple ivells list all depths rfdrjjerent(example-3@200'and 2@I001 construction to the following:
10.Static water level below top of casing• 60 (ft.) Division of Water Resources,Information Processing Unit,
I/'trater 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(gpm) Method oftest:
3 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: 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