GW1-2022-10126_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This firm can be used for single or multiple wells
1.Well Contractor information:
14.WATER ZONES I
Kolby Mitchell Sawyers FROM TO DESCRIPTION
Well Contractor Name
4471-A
NC Well Contractor Certification Number I5.OUTER CASING for multi-cased"wells)OR LINER(if a able)
FROM TO DIAMETER I THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft 54 ft' 6.25 ; in. #21 PVC
Company Name 16.INNER CASING OR TUBING eothermalclosed400
2021-00014 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: tt. ft. in.
List all applicable Hell permits(i.e.Counh;State. Variance,byection.etc.)
ft. fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER ' SLOTSIZ,E THICKNESS MATERIAL
ft. rt. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water SuPPIY(single) ft. it. in.'
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft, 20 f/ Bentonite Pumped
Note-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. rt.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stonmwater Drainage
ft. ft. I
❑Experimental Technology ❑Subsidence Control
2D.DRILLING LOG(attach additional sheets"ifnecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft- 54 ft. OVER BURDEN
10-4-2022 54 ft- 225 it• GRANITE
4.Date Well(s)Completed: Well iD#
ft. ft.
,a.Well Location:
David Livengood ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Suddreth Lane Candler, NC 28715
Physical Address,City,and Zip 21.REMARKS.
Buncombe 8695467852
County Parcel Identification No.(PIN) DWQRM
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification
nf'well field.one lat/long is sufficient) •
N W 10-24-2022
Signature of Cenifi Well Contractor Date
6.Is(are)the well(s): 2 Permanent or ❑Temporary By signing this form,I hereby certq} 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 ©No copy q/his record has been provided to the well owner.
l/thi.,is a repair.fill out known well construction itilormation and evplain the nature a/the
repair under 42l 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.
Fur multiple injection ur non-wider supph•wells ONLY with the saute construction,you can
emit one town. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple iveiih list all depths it di(jerent(example-3@200'and 2G100') construction to the following:
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
(l barer level is above casing,use + 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b. For Injection Wells ONLY: �ln 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 m 8 Method of test: RIG 24c.For Water Supply&Injection Wells:
lgP ) 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.
Forr}r GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013