GW1-2022-09465_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:
14.WATER ZONES l; '
Kolby Mitchell Sawyers FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A f. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased'i5ells)OR LINER(if a Iicable'
FROM TO DIAMETER 1 THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 28 ft 6.25 i" #21 1 PVC
Company Name 16.INNER CASING OR TUBING "ebtbermal closed-loo I
2022-00213 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List till applicable well permits(i.e.Counp,,State.Variance,htjection,etc.) in.
3.Well Use(check well use): 17,SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESZ.1.OUNT
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) E7Residential Water Supply(single) ft. it. i"•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT M
❑irrigation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVELPACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental 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' 28 ft. OVER BURDEN
8-4-2022 28 ft- 305 ft- GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Clyde Motley
ft. rt.
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft. OCT 7
116 Medford Branch Road Candler, NC 28715
ft. ft. Unit
Physical Address,City,and Zip 21.REMARKS.
Buncombe 86950774680000
Countv Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certificatiod:
(if well field,one lat/long is sufficient)
Y7VU ) 08/31/2022
N W
Signature of Certifi Well Contractor Dale
6.Is(are)the well(s): ❑O Permanent or []Temporary B,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 Construction 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.
Il7his is a repair,,lill out known well construction injbrmalion and explain the nature ofthe
repair[order#21 remarks section or on the back of this•/brm. 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 same construction,you can
suhinii one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface• 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple irells list all depths{/Vfftrent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
Illrater level is(that,(,casing,use"+'• 1617 Mafl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY: 11n 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.anger,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
20 m Method of test: RIG
13a.Yield
(gp ) 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 30 well construction to the county heilti department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013