GW1-2022-05232_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 ATER TONES DESCRIPTION
Well Contractor Name
4471-A ft. ft.
NC Well Contractor Certification Number 15..OUTER CASING(for multi-eased4e11s)OR LINER.(if a licable)'
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. 106 16.25 i" 1 #21 1 PVC
Company Name 16:INNER CASING OR TUBING(geothermal closed-too)
2021-00337 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. I in.
Gist all applicable well permits(i.e.Couno,,State.Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN ;
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESM&AMOUIT
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) El Water Supply ft. ft. i"•
o PP Y) PP Y _
❑Industrial/Commercial ❑Residential Water Supply(shared) 18..GROUT
FROM TO MATERIAL EMPLACEMENT M
❑lr1'1LTation 0 ft' 20 ft' Bentonite Pumped
Non-Water Supply Well:
rt. rt.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Cif applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology El Subsidence Control
20.DRILLING LOG(attach additional sheets i[necessar '
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,gimin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rt 106 ft OVER BURDEN
4-4-2022 106 rt 205 ft GRANITE
4.Date Well(s)Completed: Well ID#
rr. rt.
5a.Well Location:
John Shirley ft. ft,
Facility/Owner Name Facility ID#(if applicable) ft. ft. 2
25 Ashmont Drive Asheville, NC 28806
Physical Address,City,and Zip 21.REMARKS
Buncombe 9710026536000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification
(ifwell field,one tat/long is sufficient)
N W c2u 4-18-2022
Signature of Certifity Well Contractor Dale
6.Is(are)the well(s): W Permanent or ❑Temporary By signing this form,1 hereby certfv that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constniction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No copy qj this record has heen provided to the well owner.
I/`this is a repair,fill out known well construction inji nration and explain the natw•e ofthe
repair under#21 remarks section or on the back ojthis jorm. 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 s•rtppPo wells ONLY with the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 205 24a. For All Wells: Submit this form within 30 days of completion of well
For nuthiple wells list all depths ifdjllerent(example-3 u 200'and 2 rr 100') construction to the following:
10.Static water level below top of casing: 40 (ft•) Division of Water Resources,Information Processing Unit,
t/'tratcr 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 8 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.
Forfar GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013