GW1-2023-00599_Well Construction - GW1_20230105

W WELL CONSTRUCTION RECORD For Internal Use ONLY:
This loam can be used for single or multiple wells
I.Well Contractor Information:
Derrick Heath Sawyers FB WATER ZONES ;' #.
WI 9'O DESCRIP170N! '
Well Contractor Name ft. ft.
2436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a Ytcable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 71 ft- 16.25 i #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
2022-00051 FROM TO DIAMETER. THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State.Variance,hyeetion,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS Mn'rEwnt.
ft. ft. in.
❑Agricultural ❑Municipal/Public
tt. ft. in.
❑Gcothennal(Heating/Cooling.Supply) El Residential Water SuPPIY(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT .
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft' 2b ft. Bentonite Pumped.
Non-Water Supply Well:
ft. Ct.
❑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 ❑Stormwatcr Drainage
ft. ft.
❑Experimental Technology ❑Subsidcncc Control 20.DRILLING'°LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
❑Gcothennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 71 ft. OVER BURDEN
11-23-2022 71 ft• 165 rt• GRANITE
4.Date Well(s)Completed: =Well ID# ft. ft. P
5a.Well Location: ft. ft.
Clinton Ingle
Facility/Owner Name Facility ID#(ifapplicablc) ft. ft. v - u,.-?a•n a,1V i—LT,•
Ox Creek Road Weaverville, NC 28787
Physical Address,City,and Zip 21.REMARKS
Madison 976254126700000 :; ;; , �r,�:,, ; trW4
r•s l
County Parcel Identification No.(PIN) J;.Qt t.rlC'NG
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
617well field,one rat/long is sufficient)
N W 12-1-2022
Ng.at. C&tractolql, Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,I hereby certify tliat the well(s)ivas(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell 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;lhe well owner.
ll this is a repair.fill oul known well construction information and nrplain the nature of the I.
repair under#21 remarks section or an the back o/'this firm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the sane construction,Yon can
submit on•,Jann. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 165 (f.) 24a. For All Wells: Submit thi's form within 30 days of completion of well
For nuthiple wells list all depths t/'di(jerent(exanhple-3 n 200'mud 2@100') construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
1l water level is above casing,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(gym) 30 Method of test:
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 20 well construction to the county health department of the county where
constructed.
i
Torre(;W-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
a i