GW1-2022-10124_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD For Internal Use ONLY:
Thi form can be used for single or multiple wells
I.Well Contractor information:
14.WATER ZONES
Kolby Mitchell Sawyers FROM DESCRIPTION
\Nell Contractor Name
ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased'wells)OR LINER(if a'`deable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 50 ft- 16.25 1 1n #21 1 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed400
2022-00294 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft, ft. in.
List all applicable we/1 permits(i.e.County.State. Variance,hpection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN 1
Water Supply Well: FROM TO DIAMETER ! SLOT SIZE THICKNESS MATF.RIAI,
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothennal(Heating/Cooling Supply) OResidential Water Supply(single) ft. tt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL_. EMPLACEMENTS METHOD&AMOUNT
❑]rrigation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothennal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc.
❑Geothennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 50 ft. OVER BURDEN
10-10-2022 50 ft• 205 ft• GRANITE
4.Date Well(s)Completed: Well iD#
ft. it.
5a.Well Location:
Joseph Eller ft. rt.
Facility/Owner Name Facility iD#(ifapplicable) ft. ft.
Cole Road Leicester, NC 28748 ft. NOV 1
Physical Address,City,and Zip 21.REMARKS'
Buncombe 97009310660000 DWWQ/500
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification-
(if well field,one lat/long is sufficient)
N w 10/27/2022
Signature ol'CerfifilyWell Contractor Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary Br signing this form,1 hereb'v certf&that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0/00 or 15A NCAC 02C.0200 Well Consa-ttction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E!lNo copy gflhis record has been provided to the well owner.
//'dns is a repair.Jill and known well consiraclion inlirrmalion and explain the nature ofthe
repair under#21 rentarks section,or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page Ito.provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
Fur multiple injection ar uon-tracer.cupplr wells ONLY with the saute construction,yati can
suhmil One fan'm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nadtiple trells list all depths/fdi(Jerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing• 40 Division of Water Resources,Information Processing Unit,
rrruer level is above easing,use + 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: 6.25 (in.) 24b. For Infection 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.c.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
m 13a.Yield
(gP ) 10 Method of test: RIG 24c.For Water Supply&Injection I Wells:
Also submit one copy of this form within 30 days of completion of
13h.Disinfection type: PILLS Amount: 20 well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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