GW1-2022-07628_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:
I4.MrATER Zt)S
Kolby Mitche Sawyers FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
NC Well Contractor Certification Number CASING fol main cased wells OR:LINER ifa""licalile
FROM TO DIAMETER TATCKNF,SS MATFA14t
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 120 ft- 16.251 in #21 1 PVC
Company Name :16.'INNER CASING OR TUB1NCy 'eotherma'E;closed-Ipd` _
2019-00330 FRONI To DIAMF V.1t THICKNESS MATFRI41.
2.Well Construction Permit#: ft. ft. In
List all applicable ur//permits(i.e.County,State, Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 't9•SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑MurticipaUPublic
❑Geothermal(Heating/Cooling Supply) EDResidential Water Supply(single) tt. Ct. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 3R•�(3ROUT ... .. s...:.:
FROM TO MATERIAL EMPLACEMENT METHOD&.AMOUNT
011,i ation 0 et. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
.........._._......
❑Aquifer Recharge ❑Groundwater Remediation J9.SAND/GRAVEL PACK.d a" lleable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20:DRILLI]�G LOG'(artach additifirial sheets iatecesssi•V i,.... is
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/o k tv a gnin size,etc.)
❑Geothermal (Heating/Cooling Retum ❑Other(explain under#21 Remarks) 0 fr• 120 fr• OVER BURDEN
7-13-2022 120 fr• 325 fr• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: R. fr. y .
Brian Haynes
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
718 Glenn Bridge ft. Pra-.&zmong Unit
Physical Address,City,and Zip ` QG
21,RF.MARKS:;i
Buncombe 9633777062
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one IaUlong is sufficient) •
N WYaN 07/26/2022
Signature ofCertiS a Contractor Date
6.Is(are)the well(s): PlPermanent or ❑Temporary By signing this fior•m,l hereby certify thut the well(.,)was•(were)constructed in accordance
with 1 sA.NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Consfvuetion Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No copy of this record has been provided to the well ouncr.
If this is a repair,fill out known u*ell construction information and explain the nature gjdre
repair under#21 remarks section or on the hack r fthis/brm. 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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the saute 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 ifdyJioent(example-3(q�200'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 vvier 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 withi t 30 days of completion of well
12.Well construction method: constriction 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) 12 Method 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 G W-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013