GW1-2022-05091_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:
14.Derrick Heath Sawyers FROM ATERZo DESCRIPTION
Well Contractor Name ft. ft.
2436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if appll able)
FROM TO I DIAMETER I THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 192 ft 6.25 #21 1 PVC
Company Name 16,INNER CASING OR TUBING(geothermal closed-loop)
2021-00359 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Counn,,State.Variance,h:ection,etc.) R. 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) EIResidential Water Supply ft. ft. m
( � b PP Y) PP Y
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 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 El Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft, ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING•LOG(attach additional sheets if necessary)
❑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. 92 fc OVERBURDEN
4-5-2022 92 ft 305 ft GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
,a.Well Location:
Family Trust No2/William A Stark fi
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Beaverdam Road Candler, NC 28715
ft. ft.
Physical Address,City,and Zip 21.REMARKS
Buncombe 9606157713
County Parcel Identification No.(PIN)
gib.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one fat/long is sufficient)
4-21-2022
N W
Signature ofCertified Well Caatractoig Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or FlNo copy gf1his record has been provided to the well owner.
lflh%v is a repair,till out known well construction infbrmation and explain the nature of the
repair under#21 remarks section or on the back of thisform. 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 in/ec•tion or non-water supply wells ONLY with the same construction.You can
submit am%run. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple swells list all depths ffelf jerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 40 Division of Water Resources,Information Processing Unit,
ll1 rater level is ahove 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(gpm) Method oftest:
20 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: 30 well construction to the county health department of the county where
constructed.
Fors GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013