GW1-2022-07609_Well Construction - GW1_20220817

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.w"ATER zons "<
Kolby Mitchell Sawyers FROM TO DESCRIPTION
Well Contractor Name ft. ft. k
4471-A ft. ft.
NC Well Contractor Certification Number 116 OUTER CAS1No for.�niutti-efi'sed?ivells'OR(IANEts if�a 1lcablil", ..
FROM TO DiAMF,TF.R TRICKNF.SS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 155 ft- 6.25 ! in. #21 PVC
Company Name 16."INNER CA$ING.OR T,URING eotherniat cbsed Ipo `%
2021-00164 FROM IIIAMETFR THICKNESS MA FRIAL
2.Well Construction Permit#: et. ft. in.
List all applicuble well permits(i.e.Counrr,State,Yariance,Injection,etc.)
ft. fL in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
in.
❑Agricultural ❑Mtmicipal/Public
R. ft.❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) in.
1tS:GROUT a,
❑1ndustriaUm Comercia l ❑Residential Water Supply(shared) "'" "'
FROTI TO MATFRIAL EMPLACEMENT MF.TAOD&.AMOUNT
❑hri ation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.S �iD1(;RA VELPACKi if-a Cable .... ..
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stomiwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control _
20i15RIL11NG l OG attafli additioa6l sliee[s:ifiecessa
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardness,soiurmk tv e.grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 f° 55 fr OVER BURDEN
7-28-2022 55 rt• 185 rr• GRANITE
4.Date Weft(s)Completed: Well 1D# ft. ft.
5a.Well Location: rt. ft. _
R & S Investments ft, ft. a s '
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Indian Paintbrush Lot 34 ft. ft. -
Physical Address,City,and Zip 21 RENJARKS: �`'s
Buncombe 9721157876 Dtig,� o�
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 07/29/2022
Signature of CatififVell Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this finm.i hereby certify that the w'ell(s),vas(were)constructed in accordance
pith 15A NCAC 02C.D100 nr 15A NCAC 02C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy of this reeord has been provided io the well owner.
If this is a repair.fill uut knuww well construction information and explain the nature ufthe
repair under#21 remarks section or on the hack ofthis/i,rm. 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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-neater.supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiIf rent(example-3(a�00'and 2(a.•100') construction to the following:
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
If wmier level is above easing.use•'+'• 1617 Mail Service jCenter,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: constnuction 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
l
15 RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
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 G W-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013