GW1-2022-09459_Well Construction - GW1_20221017

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This Ibrm can be used for single or multiple wells
1.Well Contractor information:
14.WATER ZONES i
Derrick Heath Sawyers FROM TO DESCRIPTION
Well Contractor Name
fc. ft.
2436-A
NC Well Contractor Certification Number 15.OUTER CASING'(for multi-casediwells)OR LINER(if a Eh ble)
FROM I TO I DIAMETER I THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 170 ft• 6.25 in #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop),
2022-00384 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List uU applicable tell permits(i.e.Couno,,State. Variance,h jection,etc.)
ft. rt. in.
3.Well Use(check well use): 17.SCREEN,
Water Supply Well: FROM TO DIAMETER SLOTSIZF. THICKNESS MATERIAL
ft. ft.❑.Agricultural ❑Municipal/Public in.
❑Geotheruml(Heating/Cooling Supply) El Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irieation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
rt. rt.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHODft. ft.
❑Aquifer Test ❑Stonnwater Drainage
ft, rt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional;sheets if necessary)-'
❑Geothermal(Closed Loop) ❑TIacer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 70 ft. OVER BURDEN
9-19-2022 70 ft• 365 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
Sa.Well Location:
Steven Schultz ft. ft.
Facility/Owner Name Facility iD#(if applicable) ft. ft.
130 Charity Lane Candler, NC 28715
Physical Address,City,and Zip -
21.REMARKS _ `;tt� � t��: 1 ?`T r .t.,
Buncombe 86885001290000 >>/ �
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one]at/long is sufficient)
N W 9-22-2022
Signature orCertiried Well Contracto Date
6.is(are)the well(s): 2Permanent or ❑Temporary By signing this fonn,I hereby certiw thai the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or/5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo coP),gfthis record has been provided to the well owner.
/(this is a repair,flill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back o/'this,%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: 1 construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-water supply wells ONLY with the saute construction,you can
srdnnit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 365 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tjdi(jerent(example-3@_700'and 2 cJ100') construction to the following:
10.Static water level below top of casing: 50 (ft,) Division of Water Resources,Information Processing Unit,
If a ate•level is above cursing,use"+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection Wells ONLY: in addition to sending the form to the address in
ROTARY 24a above, also subunit 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
13tt.Yield(-pm) Method of test:
2 RIG 24c.For Water Supply&Injection,Wells:Also submit one copy of this form wi,.thin 30 days of completion of
131).Disinfection type: PILLS Amount: 35 well construction to the county healthl department of the county where
constructed.
Fora GW-I North Carolina Department of Environment and Natural Resources-Division of Water Re son rces Revised August 2013