GW1-2022-07627_Well Construction - GW1_20220817

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
IQ.n'ATER ZQl!iES
Derrick Heath Sawyers FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2436-A ft.
NC Well Contractor Certification Number tS.OUT ft'CASING-for.iirald cased>wells UR LINER f:a lteatile>
FROM TO DIAMETER THICKNFSS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 H. 106 ft- 16.25 #21 1 PVC
Company Name 46.INN£R CA$tNGOR TUBING cothenrtal closed-I.61RL4L.,
2021-00482 FROM DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: R, ft. In
List all applicable aYll permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): ,f7.:SCREf N
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft.❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single)
ft. ft. in.
01ndustrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
011-rigation 0 ft' 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SANIIIt;RA�ELPACK da' 'cable
FROM TO MATERIAL EMPLACEMENT 51ETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
..20 ID, 6, . ...... .
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardnes soittrock tv a grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 106 ft. OVER BURDEN
04-05-2022 106 ft- 505 ft. GRANITE
4.Date Well(s)Completed: Well 1D# ft. ft.
5a.Well Location:
Javan Lazarus
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
513 Laurel Cove Rd ft. ft.
Physical Address,City,and Zip 21;;REMARKS''
Buncombe 869904421800000 1 1 Z 0 Z 2
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 �nr ..� 7-25-2022
Signature of ertified Well CuntractcV Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this fiorm,i herehv certify'that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 nr 15A NCAC 02C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofthis record has been provided to the well owner.
Ifthis is a repair.fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of.
f 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
submit one form. 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
For multiple wells list all deaths if diffierent(example-3(p�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 water level is above easing.use '+^ 1617 Mail Servicetenter,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 die following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail ServicelCenter,Raleigh,NC 27699-1636
13a.Yield m 3 Method of test: RIG 24c.For Water Supply&Injection Wells:
(gP ) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS .Amount: 20 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Envirunment and Natural Resources-Division of Wate'r Resources Revised August 2013
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