GW1-2022-09455_Well Construction - GW1_20221017

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Kolby Mitchell Sawyers F4.WATER ZONES FROM 'I'O DESCRIPTION
Well Contractor Name ft. ft.
4471-A
NC Well Contractor Certification Number 15...OUTER CASING(for multi-cased wells)OR LINER(if a licable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 120 f- 16.25 #21 1 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
2022-00011 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Count),,State.Parlance,Injection,etc.) ft. ft.
in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal Heating/Cooling Supply) El Water Supply ft. ft. in.
( b PP Y) PP Y
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft, Bentonite Pumped
Noll-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation .19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stonmwater Drainage
ft. ft.
❑Experinmcntal Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) 0 ft 120 ft OVER BURDEN
9-2-2022 120 ft 205 ft GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
Sa.Well Location: ft. ft.
Maureen Sturgis ft. ft.Facility/Owner Name Facility ID#(ifapplirable) ft. ft. O C T 17 2022
Burney Mtn Rd Fairview, NC 28730
Phvsical Address,City,and Zip f -�
21.REMARKS
Buncombe 9674952995 ;�:r` - • j
Countv .Parcel Identification No.(PM)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification-
(if well field,one ha/long is sufficient)
N W 09/21/2022
Signature orCertifilyWell Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary 13v signing this form,I hereby certJv that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well ConstYtction Standards and that a
7.is this a repair to an existing well: ❑Yes or ONo copy of This record has been provided to the well owner.
ll'this is a repair,Jill out known well construction hijbrntation and explain the nature of the
repair under#21 remarks section or on the back of this fornz. 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: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the sarne construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 205 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi(ferent(example-3 u 200'and 2G100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
11ister level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY: Iln 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail.Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 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: 20 well construction to the county healt} department of the county where
constructed. I I
u
Form CiW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013