GW1-2023-00661_Well Construction - GW1_20230105

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This firm can be used for single or multiple wells
1.Well Contractor information:
Kolby Mitchell Sawye FROM
rs ER ZONES
FROM '1'O DESCRIPTION
ft.
Wel I Contractor Name ft. i
4471-A
NC Well Contractor Certification Number 15,OUTER CASING(for multi-cased`wells)OR LINER(if a livable)
FROM TO DIAMETER I F THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 168 It- 6.25 I i #21 1 PVC
Company Name 16.INNER.CASING`OR TUBING(geothermal closed-loop)
2022-00111 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. rt. in.
List all applicable well permits(i.e.Counly,State,Variance,hyection,etc.) ft. ft. i in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) FlResidential Water Supply(single) ft• rt• m.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 It- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK ifa livable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwatcr Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain sae,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rt. 68 tt. OVER BURDEN
11-8-2022 68 ft• 345 It- GRANITE
4.Date Well(s)Completed: Well iD#
et. rt.
Sa.Well Location: rt. ft. _,
Bradley Silvers
1t
Facility/Owner Name Facility ID#(ifapplicable) JQN Q 2Q23
Clara Springs Drive Weaverville, NC 28787 ft. rt.
Phvsical Address,City,and Zip 21.REMARKS 'tt' "`'
Buncombe
County Parcel Identification No.(PIN)
ib.Latitude and Longitude in degreesiminutes/seconds or decimal degrees: 22.Certification:
Iitwell field,one tat/long is sufficient)
ii
11-15-2022
N W
Signature orCertif-ifyWell Contractor Date
6.Is(are)the well(s): 2 Permanent or ❑Temporary By signing this form,I hereby certi1v that the svell(s)was(were)constructed in accordance
vit h 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 ElNo Copp gf1his record has been provided to the well owner.
p this is a r(Tair.ill oat known avell construction in��rwadon and explain the nature of the
repair under#21 remarks section or on the back ojthisfornt. 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.
Fin-outhiple injection or non-irate,•sttpplr wells ONLY with the same construction,you can
,nbn,it one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 345 (ft.) 24a. For All Wells: Submit this ilform within 30 days of completion of well
hit-inuhiple irellr list all depths fff'd?ftr•ent(example-3@200'and 2@100') construction to the following: p
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
i/'arater 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,iUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I
13:t.Yield(gpm) Method oftest:
7 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' 35 well construction to the county he�lth department of the county where
constructed.
Furor CiW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013