GW1-2022-05926_Well Construction - GW1_20220627

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor information:
14.WATER ZONES 4
Kolby Mitchell Sawyers FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(tor multi-eased wells)OR LINER(ita hSable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 62 ft 6.25 1° #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2021-00572 FRONT TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable rrell permits(i.e.County,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
in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) 711esidential Water SuPP1Y(single)
❑Industrial/Commercial ❑Residential Water Supply 18.GROUT
pp y(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrr; ation 0 it. 20 ft- Bentonite Pumped
Non-Water Supply Well:
❑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 ❑Salinity Barrier
❑Aquifer Test ❑Stormwatcr Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessar ,
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks)J 0 ft. 62 ft. OVER BURDEN
5-16-2022 62 ft- 505 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Larry Jason Mullinax ft. ft. -
Facility/Owner Name Facility ID#(if applicable) ft. ft. J U N ( .
2022
Sharon Ridge Road Fairview, NC 28730
Physical Address,City,and Zip 21.REMARKS
Buncombe 9685273998
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification•
(if well field,one]at/long is sufficient)
N W 06/01/2022
Signature ofCerlificyWeli Contractor Date
6.Is(are)the well(s): R Permanent or ❑Temporary By signing this form,I herebv certiJ,b that the rrell(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 iJNo copy gfthis record has been provided to the well owner.
I/this is a repair,Jill out known well construction infbnnation and explain the nature of the
repair under#21 renurrlrs section or on tine back oJ'this form. 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 if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
stth,nit one Jornn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 505 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
depths i•di Brent(example-3 c 200'and 2 100' construction to the following:
For mahiple wells list all dep s / JJ ( p @ @ ) g
10.Static water level below top of casing• 50 Division of Water Resources,Information Processing Unit,
/jnater•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
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ROTARY 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
2 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: 35 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