GW1-2022-10137_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This liirm can be used for single or multiple wells
I.Well Contractor information:
Kolby Mitchell Sawyers FROM WATER a;
FROM 'r0 DESCRIPTION
Well Contractor Name
rt. rt.
4471-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER(if a""fieable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 75 ft- 6.25 i" #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed400
2022-00349 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
list all applicahle well permits(i.e.Counh•,State. Variance,hyection.etc.) ft. it. in.
3.Well Use(check well use): 17.SCREEN
H'aterSupply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public in.
❑Geotheral(Heating/Cooling Supply) EIResidential Water Supply(single) ft. rt. in.
m
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 rt. 20 ft- Bentonite Pumped
Non-Water Supply Well:
❑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
❑Aquifer Test ❑Stor nwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.-DRILLING LOG attach additional sheets if necessar
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/mck e, rein size,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rt. 75 tt. OVER BURDEN
9-20-2022 75 it 245 it GRANITE
4.Date Well(s)Completed: Well iD#
5a, Well Location:
Earl & Jane Davis
facility/ONner Name Facility iD#(ifapplicable)
400 Billy Cove Road Candler, NC 28715 ft. it. NOV 1 O 2022
Physical Address,City,and Zip 21:'REMARKS
Buncombe 9605645166000 JnOows"on ProcaesiV U
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification-
I f'%%ell field,one fat/long is sufficient) :.
N N 011-1-2022
Signature of-Certifi Well Contractor Date
6.Is(are)the well(s): R Permanent or ❑Temporary Br signing this lbrm,I hereby certiJv that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or KNo cony gfthis record has been provided to the well owner.
/(Ibis is a repair.Jill out known well construction iglormalion and erplain the nature of the
repair under#21 remarks section or on the hack o/'thisJorm. 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 ifnecessary.
For multiple injection ur non-wafer suppfr wells ONLY with the same construction,yrm can
subniii one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 245 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths il'di(Jerent(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,
(1 hater level is above easing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection 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
13a.Yield(gpm) Method of test:
6 RIG 24c.For Water Supply&Injection�Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 25 well construction to the county health department of the county where
constructed.
Fortat GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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