GW1-2022-05089_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 14.
FROM FROM
ZONES
noM To nEscntPTloN
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS I1fATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 17s ft 6.25 ' 1 #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2021-00154 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable urll permits(i.e.County,State. Variance,hyeetion,etc.) ft ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) El Residential Water SuPP1Y(single) '18 ft. ft. in•
❑Industrial/Commercial ❑Residential Water Supply(shared) R GROUT' '
FRO\I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 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 fr. ft.
❑Agtlifct•Test ❑Stonnwatcr Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 76 ft. OVER BURDEN
4-4-2022 76 ft 165 ft• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
B&B Developers
Facility/Owner Name Facility ID#(ifapplicable) .- y
111 Oak Mtn Drive Leicester, NC 28748 ft. ft. -
Physical Address,City,and Zip 21.REMARKS
Buncombe 8790205914
County Parcel Identification No.(PIN) L's}r`.^ i�h<i �151i tj;l l
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: t'rl f i'a1t i"
22.Certification:
(if well field,one lat/long is sufficient)
N N VJ_ 5/18/2022
Signature ofCertifi Well Contractor Date
6.Is(are)the well(s): R Permanent or ❑Temporary By signing this fonn,1 hereb),certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200{Yell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo cop),of 1his record has been provided to the well owner.
1Ohis is a repair,Jill out known well construction information and ccsplain the nature ofthe
repair under#21 remarks section or on the back oj'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 if necessary.
For nrdliple injection or non-water supp(v wells ONLY with the saute construction,you can
snhinit one.jorrrr. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 165 _(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nmhiple wells list all depths ifdijjcrent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 20 Division of Water Resources,Information Processing Unit,
{water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter 6.25 (in.) 24b.For Injection 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 m 12 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: 20 well construction to the county health department of the county where
constructed.
Forum CiW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013