GW1-2023-00656_Well Construction - GW1_20230105

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WELL CONSTRUCTION RECORD For Internal Use ONLY: ii
This form can be used for single or multiple wells
1.Well Contractor information:
14.WATER ZONES
Derrick Heath Sawyers FROM DESCRIPTION
Well Contractor Name
ft. ft.
2436-A I ft. ft.
NC Well Contactor Certifieation Number 15.OUTER CASING(for multi-cased wells)OR LINER(ifa ticable
FROM TO DIAMETER I THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 155 ft- 16.25 in. #21 1 PVC
Company Name 16.INNER CASING OR TUBING eoth irmal closed-loop)
2022-00�78 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 8 ft• ft• ! in.
List all applicable trell permits(i.e.County,State.Variance.hjection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM - TO DIAMETER SLOT SIZE THICKNESS MATF.RIAI.
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) FIResidential Water SuPP1Y(single) ft. ft. in.
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❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrrivation 0 ft' 20 ft. Bentonit'e Pumped
Non-Water Supply Well:
ft. ft.
❑p9on itoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK(if applicable)
FROM TO \tATER1AL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aqui fa•Test ❑Stornwater Drainage
❑Esperinmcntal Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,saillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 55 ft. OVER BURDEN
5-18-2022 55 ft- 465 ft. GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location:
Jakilynn Jefferis
Facility/Owner Name Facility ID#(ifapplicable) ft. ft
42 Little Oak Road Leicester, NC 28748 ft. ft. p
Physical Address,City,and Zip 21.REMARKS
Buncombe 97031120790000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifieation:
(if well field,one hat/long is sufficient)
N W 12-6-2022
Signaluvra oof ertified Well Contractoo, Date
6.is(are)the well(s): ❑O Permanent or ❑Temporary BY signing this form,I herebp certi/ that,the well(s)was(were)constructed in accordance
with I5A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy ofllds record has been provided to die well owner.
II This is a repair.fill oal known Ivell construction it fo nlallon and arplain the nature ofdie
repair under#21 remarks section or on the back of this firm. 23.Site diagram or additional well details:
You may use the back of this page io provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
Fw-out/riple h jetting in,non-water suppt7 wells ONLY with the same construction,you can
submit nne farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface• 465 (ft.) 24a. Far All Wells: Submit this!form within 30 days of completion of well
1--or multiple wells list all depths ifdi(/erent(example-3@200'and 1@I00') construction to the following: Ij
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10.Static water level below top of casing: 80 (ft.) Division of Water Resources,Information Processing Unit,
If hater level is above casing,use'+ 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6.25 (in.) 24b.For Injection 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
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13a.Yield(gpm) Metlmod of test: i
3 RIG 24c.For Water Supply&InjectionrWells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 30 well construction to the county health department of the county where
constructed. `
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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