GW1-2022-07620_Well Construction - GW1_20220817

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Derrick Heath Sawyers FROM TO .--
FROM TO DESCRIPTION
Well Contractor Name ft. ft. !
2436-A
NC Well Contractor Certification Number 15•.fJl1TER CAStNG'14,i iulh caeeil wells Olt L]NERltVik is
FROM TO DIAMFTER TATCKNFSS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 l" 172 a. 6.25 ', in 421 1 PVC
td.')1Vt±t£R CA$IjvC,OR 1tIBINPx eot.b tmaUicw 44,14o
Company Name � _ .........._.
2022-00363 FROM 10 DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft in
List all applicable vivIl permits(i.e.County.State,Variance,Injection,etc.)
in.
3.Well Use(check well use): t?.-SCt2EEhi._...' ,
Water Supply Well: FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
in.
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) OResidential Water Supply(sin(single) ft ft. in.
❑lndustriallCommercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Oli-rigation 0 20 ft- Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 29,:Sd1YI37C;R"tSLi'r40K`"d-a ii61e ..-.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DAILid1VG;'OG{attaeti addit;a r sTteetsaiecessary-°=
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rack tv a grain size,etc.)
❑Geothermal (Heating/Cooling Return ❑Other(explain under 921 Remarks)J 0 R' 72 fr' OVER BURDEN
fr• N
4.Date Well(s)Completed: 07-13-2022 Well ID# 72 325 GRANITE
ft. ft.
5a.well Location:
Jennifer Black
Facility/Owner Name Facility ID#(if applicable) ft, ft.
311 Herron Point LN
Physical Address,City,and Zip
Buncombe 974270608100000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one Iat/long is sufficient)
N w 7-14-2022
Signature of ertified Well CtTotractV j Date
b.Is(are)the well(s): ❑✓Permanent or ❑Temporary By signing this form./herebv certify that the well(,)ivas(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 H'ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ZNo copy of this record has been provided to the well owner.
If this is a repair,fill out Anuity well construction information and explain the nature of the
repair under#21 remarks section or on the back c f this form. 23.Site diagram or additional well details:
You may use the back of this page Ito 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 a'non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 325 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiJferenl(example-3(u00'and 2(ar100') construction to the following:
10.Static water level below top of casing: 30 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 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.) P
Division of water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m 12 Method of test- RIG 24c.For Water Supply&Injectionl.Wells:
(gP ) Also submit one copy of this fol'm within 30 days ofcompletion of
13b.Disinfection type: PILLS Amount: 20 well construction to the county heal Ith department of the county where
constructed.
Fora GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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