GW1-2022-05919_Well Construction - GW1_20220627

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 ATER'Z ONES DESCRIPTION
Well Contractor Name ft. ft.
2436-A ft. fr.
NC Well Contractor Certification Number '15.OUTER CASING(for multi-eased<�iells)OR LINER(if a ticable)
FROM I TO I DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 it. 72 fc. 6.25 1° #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed400
ft,
• in.2022-00075 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#. ft.
List all applicable well permits(i.e.County,State, Variance,byection,etc.)
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(single) ft. ft.
d PPY) PPY( g )
❑Industrial/Commercial ❑ 18Residential Water Supply(shared) GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 20 ft- Bentonite Pumped
Non-Water Supply Well:
rt. rt.
❑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 if necessary),
❑Geothermal(Closed Loop) ❑Tracer r72ft-
TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 72 ft OVER BURDEN
5-31-2022 285 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft.
5a.Well Location: rt.
Chelsie Roberts
Facility/Owner Name Facility ION(ifapplicable) u y V
Bob's Haven Road Leicester, NC 28748 ft. I ft.
Physical Address,City,and Zip 21.REMARKS
Buncombe 9703542742
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one hit/long is sufficient)
N W 6-6-2022
Signature of Certified Well C6ntracto6F Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby certify that the tvell(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 ©No copy of this record has been provided to the well owner.
Il'this is a repair,ffill out known well construction information and explain the nature ofthe
repair under#21 remarks section or on the back oj'thisforn,. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages ifnecessary.
For multiple injection at,non-water supply wells ONLY with the scone construction.You can
.smbutil nne form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface• 285 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 20 Division of Water Resources,Information Processing Unit,
If 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
I
13a.Yield(gpm) 100 Method of test• RIG 24c.For Water Supply&Injjection 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.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013