GW1-2023-00670_Well Construction - GW1_20230105

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
i
1.Well Contractor Information:
Kolby Mitchell Sawyers FROM TO DESCRIPTION
Well Contractor Name ft. ft,
4471-A
NC Well Contractor Certification Number 15:OUTEIi'GAStIYG.for mast cased svelte OR DINER f s` hcable
FROM TO DIAMF,TF.R THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. 150 ft. 6.25 in
#21 PVC
Company Name ib.:11V1VER:GA$t111(x't)R'ttlBlltiG tPthernigl'slosedlOo
2022-00401 FROM 10 DIAMFIF:R THICKNESS MATF.HIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft ft. in.
3.Well Use(check well use):
WateYSUpplyWell: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
ft. ft. in.
❑Geothermal(Heating/CoolingSupply) OResidential Water Supply(single)
_
f8'GROtiT. ..
❑IndustriaUCommercial ❑Residential Water Supply ~hared)
pp y( FROM TO MATE-RiAL EMPLACEMENT METHOD&.4NOl1VT
131ni ation 0 rt. 20 ft• Bentonite Pumped
Non-Water Supply Well:
Ct. tt.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑A uifer Recharge ❑Groundwater Remediation 1➢SSA TDIeRAVEL3'AGeowpNo
FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier [t. ft.
❑Aquifer Test ❑Stormwater Drainage
[t. fr. ,
❑Experimental Teclmology ❑Subsidence Control
20 ORIICL1NGr1OG.attaeliadr fit
a""Ishee[s:iliiecessa
❑Geothermal(Closed Loop) []Tracer FROM I TO DESCRIPTION color,hardness,soiurockty a gnin size,etc.)
❑Geothermal (Heating/Cooling Retum) 00ther(explain under 921 Remarks) 0 it• 150 ff• OVER BURDEN
11-28-2022 150 it• 305 it• GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location:
Samuel Parham
Facility/Owner Name Facility ID#(if applicable) F — ,>
is rZ L
60 Sandy Hollar LN rt.
Physical Address,City,and Zip 21 ttEMARKS.. ...
a
Buncombe 87610973720000 Ur
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one fatllong is sufficient)
N W 12/02/2022
Signature ofCcitifilfwell Contractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this fo m,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Nell Consi•uction 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 due nature of the
repair under 921 remarks-section or on the back ofthhvJbrm. 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 or non-water suppl)�wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface• 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple ivellr list all depths iij'efi ferenI(example-3(dJ200'and 2Gw100) construction to the following:
i -
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection 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) O
p 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 35 well construction to the county �ealth department of the county where
constructed.
Forffi GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013