GW1-2022-09469_Well Construction - GW1_20221017

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers F4.WATERZONES
FROM TO DESCRIPTION
Well CContractorft.
actor Name ft. '
4471-A
NC WelI Contractor Certification Number' 15.OUTER CASING(for multi-cased:wells)OR LINER(if a licable)
FROM I TO I DIAMETER I THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 70 ft. 6 1/8 in #188 1 steel
Company Name G 16.INNER CASING'OR TUBING(eothertnal closed400.
2022-00076 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List till applicable well permits(i.e.Cottno,,State.Variance,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) ElResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 et. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable),,
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifcr Test ❑Stonrtwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
211:DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑TIacer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Fleating/Cooling Return) ❑Other(explain under 921 Remarks) 0 ft. 70 ft. OVER BURDEN
9-8-2022 70 fc. 305 fr GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft. -7
7-1
Mark Massey ft. ft. x•t .d=?�� .
au
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
609 Old Fort Road Fairview, NC 28730 ft. ft.
Physical Address,City,and Zip 21.REMARKS t+wi.` s•=°` j'LntY ,
Buncombe 969608068600000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
N N 9-13-2022
Signature ofCertifi Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certiw that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constrzrction 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 it repah-Jill out known well construction ht(brtnation and explain the nature ofthe
repair under#21 remarks section or on the back of this for»t. 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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water sttpph•wells ONLY with the same construction,you can
snbmil one Jortn. 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 wells list all depths Y'd4jerent(example-3 cJ200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
/f water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection 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 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
i
13a.Yield(gpm) 10 Method of test: RIG 24c.For Water Supply&Injection Wells:
C Also submit one copy of this form within 30 days of completion of
13b PILLS 3J.Disinfection type: Amount: well construction to the county healthi department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013