GW1-2022-10125_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
14.WATER ZONES
Kolby Mitchell Sawyers FROM TO DESCRIPTION
Well Contractor Name ft. ft. i
4471-A f`
NC Well Contractor Certification Number ,15.OUTER CASING(for multi-easedivells OR LINER(ifa` ticable
FROM TO DIAMETER f THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 1I. 80 ft 6.25 ' i #21 PVC
Company Name Q 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO '
2022-00004 DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. Iin.
List all applicable well permits(i.e.Counly,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.
❑Aericultural ❑Municipal/Public
ft. tt. in.
❑Gcothennal(Heating/Cooling Supply) El Residential Water SuPPIY(single)
❑industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Initiation 0 ft• 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwatcr Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 80 ft. OVER BURDEN
10-5-2022 80 ft- 265 tt• GRANITE
4.Date Well(s)Completed: Well ID# ft ft
5a.Well Location: ft. ft.
Alan Israel
Facility/Owner Name Facility ID#(ifapplicable)
75 Lon Israel Road Candler, NC 28715
Physical Address,City,and Zip 21.REMARKS NOV
Buncombe 8695281546
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification-
(if well field,one W/long is sufficient)
N W 10-24-2022
Signature of Certifh Well Contractor Date
6.Is(are)the well(s): ❑✓Permanent or ❑Temporary Br signing this form,1 herebv certfv 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 cop)'ofthis record has been provided to the well owner.
117hi.s is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 remarks section or on the back o/'this form. 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.
ror nuhiple injection or non-water supply wells ONLY with the setae construction,you can
subau one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nnthiple wells list all depths r/'di(ferent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
lflralcr level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For[niection Wells ONLY: 4n 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,jUnderground 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 forrn within 30 days of completion of
13b.Disinfection type: PILLS Amount• 25 well construction to the county heal Ith department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013