GW1-2022-05921_Well Construction - GW1_20220627

WELL CONSTRUCTION RECORD For[ntemaI Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Derrick Heath Sawyers FROM WATER TONES= DESCRIPTION
Well Connector Name ft. ft.
2436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased'wells)OR LINER(if a `Gcable)
FROM I TO IDIAMETER I THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft 36 ft 6.25 in. 1 #21 1 PVC
Company Name 16.INNER CASING OR TUBING eothermaI closed-loop),
2021-00238 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Count),,State,Variance,h jection,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) E lResidential Water Supply(single) ft. ft. in.
a PP Y) PP Y( � g )
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrrl ation 0 ft' 20 tt, Bentonite Pumped
Non-Water Supply Well:
rt. rt.
❑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 ❑Stonnwater Drainage
rc. rc.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessar
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rt' 36 tt OVER BURDEN
2-12-2022 36 rt 305 tt GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Monica Marshall
Facility/Owner Name Facility lD#(if applicable) ft. ft.
130 Saddle Ridge Estates Alexander, NC 28701 rt. rt.
Physical Address,City,and Zip 21.REMARKS
Buncombe 971288872600000 Inc,:, .. :, « •.L�.t:,� Urli.
County Parcel Identification No.(PIN)
5b.Latitude'and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
N W 6-2-2022
Signature of Certified Well Cc ntractojq Dale
6.Is(are)the well(s): ❑O Permanent or ❑Temporary Br signing this form,I hereby certify that the we/l(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 cop),ofthis record has been provided to the well owner.
Ifthis is a repair,till out known well construction information and explain the nature of the
repair under#21 remarks section or on the back ofthisform. 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 supply wells ONLY with the same construction,you can
submit one form. 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 wells list all depths ifdt,'llerenl(example-3 a 200'and 2 a 100� construction to the following:
10.Static,eater level below top of casing.40 (ft,) Division of Water Resources,Information Processing Unit,
1f water level is above casing,use•'+•' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection 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)
6 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this fore 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 201,