GW1-2022-10127_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This lixm can be used for single or multiple wells
I.Well Contractor information:
14.WATER ZONES
Kolby Mitchell Sawyers FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number 15.'OUTER CASING for multi-cased;wells O!LINER ifa ticable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 55 ft- 6.25 in. #21 PVC
Company Name 16.INNER CASING OR TUBING "eothermal'closed400
2021-00688 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Counh,,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
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in,
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
El 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/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG:attachadditional beets if necessa -
❑Geothetmal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soittrock e, rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 55 ft. OVER BURDEN
10-13-2022 55 ft- 205 ft- GRANITE
4.Date Well(s)Completed: Well iD#
ft. ft.
5a.Well Location:
Jonathan A Taylor
Facility/Owner Name Facility ID#(ifapplicable) ft ft
370 Turkey Creek Road Leicester, NC 28748
Physical Address,City,and Zip 21.REMARKS
Buncombe 8792723683 r"
County Parcel Identification No.(PIN)
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5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
N W 10/13/2022
Signature ofCertil, Well Contractor ! Date
6.iF(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
With I5A 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 ElNo copy of this record has been provided to the well owner.
Ifihis is a repair,fill out known well construction information and erplain the nature ofthe
repair undo#21 remarks section or on the back gl'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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water•svpp(v wells ONLY with the saute construction,you can
snbmil auejorm. 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 multiple wells list all depths iI'di(ferent(example-3 a 200'and 2@u 100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Res t rces,Information Processing Unit,
if toter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter 6.25 (in.) 24b.For iniectic Wells ONLY:i iti 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
m 13a.Yield
(gp ) 15 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
PILLS
13b.Disinfection type: Amount: 20 well construction to the county heialth department of the county where
constructed.
Fond GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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