GW1-2023-00663_Well Construction - GW1_20230105

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WELL CONSTRUCTION RECORD
For Internal Use ONLY: ,
This form can be used for single or multiple wells
1.Well Contractor Information:
,'14:•�YA1'ER=Z01�I8S
Kolby Mitchell Sawyers FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471—A ft. ft.
NC Well Contractor Certification Number 16OUTPRCASIBIG ftir7iuH3cased vells'OR'L1NER'ifs 'licabk'
FROM TO DIAMETER MATERIAL
MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 fr- 43 ft- 6.25 #21 1 PVC
Company Name UBINfa,k6f1i6rmei closed l04"
2021-00490 FROM to DIAMN:rER THICKNESS MATERIAL
2.Well Construction Permit#: ft. rt. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft ft in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft• ft. in.
❑Geothermal(Heating/CoolingSupply) BResidential Water Supply ft. ft. in.
pp Y) pP Y(single)
❑IndustriaUCommercial ❑Residential Water Supply(shared) « ._. .
FROM TO MATERIAL F.MPLACF.MF.NT METHOD&AMOUNT
❑hTi ation 0 ft' 20 fir Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
[]Aquifer Recharge ❑Groundwater Remediation :19,:SANAfGi AXIEL PAGE;tf a' 'able __
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery []Salinity Barrier
tt. tt.
❑Aquifer Test ❑Stormwater Drainage
ft ft.
❑Experimental Technology ❑Subsidence Control
.ZO-tlR1GLINGaY'i1G'attaeli addltitii5lsheets'id'lecessa .._ ..... .--....:.
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soivrock type. ram size,etc-)
❑Geothermal (Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 43 ft- OVER BURDEN
12-05-2022 43 fr• 165 ft. GRANITE
4.Date Weil(s)Completed: Wel1ID# ft. ft.
5a.Well Location:
ft. ft• 4 v r d '
Randall Willis ft. ft. ' - v ).1, 8--F
Facility/Owner Name Facility ID#(ifapplicable) g. ft. CO23
120 Saddle Ridge, Lot 7
rc ft.
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Physical Address,City,and Zip
Buncombe 97128848900000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N W 01/03/2023
Signature ofCcitififWell Contractor Date
6.is(are)the well(s): 1]Permanent or ❑Temporary By signing this form,I herehl'certify t/rut the wells)was(were)constructed in accordance
with 1SA NCAC 02C.0100 nr 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remark,section or on the back tfihis 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 ifnecessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. cG SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 165 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdJferent(example-3(d 00'and 2(a,1001 CDnStnlCtlon t0 the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above easing.use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY: iIn 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.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method of test• RIG 24c.For Water Supply&Injectioni Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 35 well construction to the county healt department of the county where
constructed.
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Focal GW-1 North Carolina Department of Environment and Natural Resources—Division of Water R i sources Revised August 2013