GW1-2022-05104_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:
Derrick Heath Sawyers FRO ATERZONE5 DESCRIPTION
Well Contractor Name ft. ft.
2436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased'wells)-OR LINER(if applicable'
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. 89 fr. 6.25 1° #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-too S
2021-00650 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Counp,,State.Variance,11 jection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
in.
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(sin(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) t9.GROUT
FROM 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 ft. ft.
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets it necessa
❑Geothermal(Closed Loop) ❑TIaceI FROM TO DESCRIPTION(color,hardness,soillrock type,grain sae,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) 0 ft. 89 rt. OVER BURDEN
3-20-2022 89 rt 205 ft GRANITE
4.Date Well(s)Completed: Well ID#
rt. ft.
5a.Well Location: ft. ft.
David Runion
Facility/Owner Name Facility ID#(if applicable) 1
1155 Old Ford Road Fairview, NC 28730 ft, ft. A _.4
v� � � 1�1 •�..�i t�,l
Physical Address,City,and Zip 21.REMARKS'
Buncombe 060629079100000
VM11�ttV
County 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 W 4-11-2022
Signature of Certified Well Contracto Date
6.Is(are)the well(s): OPermanent or ❑Temporary ev signing this form,1 herebv fv tha
t 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 E]No copy gfthis record has been provided to the well owner.
lfdhis is a repah-Jill out known well construction iglbrnalion and explain the nature of the
repair ander•#21 ren arL section or on the back gfthis jbra. 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-water supph•wells ONLY with lire sane construction,yntic-an
submit one faro. 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 irells list all depths tfdiftrent(example-3 a 200'and 2@100') construction to the following:
10.Static water level below top of casing: 50 (ft.) Division of Water Resources,Information Processing Unit,
(f 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(gym) Method
6 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: 20 well construction to the county health department of the county where
constructed.
Forea GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013