GW1-2023-01942_Well Construction - GW1_20230227

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
o
Kolby Mitchell Sawyers FROM TO DESCRI I MON
Well Contractor Name
4471-A
NC Well Contractor Certification Number
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 It- 107 ft- 6.25 i in. #21 PVC
Company Name 1401KM 01�1
FROM rO [)]AmF,,rF.R THICKNESS MATERIAL
2.Well Construction Permit#: 2022-00539 It. ft. in.
List all applicable sivil permits(i.e.County,State,Pariance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural OMurlicipal/Public I
DGeothermal(Heating/Cooling Supply) EIResidential Water Supply(single) n.,
01ndustrial/Commercial DResidential Water Supply(.shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
olii�igation 0 ft' 20 ft- Bentonite Pumped
Non-Water Supply Well:
fit. fit.
Efflonitoring DRecovm-y
Injection Well:
OAquifer Recharge OGromidwater Remediation
FROM TO MATERIAL EMPLACEMENT METHOD
E]Aquifer Storage and Recovery El Salinity Barrier ft. ft.
DAquifer Test 0 Stormwater Drainage ft. ft.
DExperimental Technology El Subsidence Control2t1'4ft 'IL I ANGLO", '(a fir 'Ww"IMirei sa
EiGeothermal(Closed Loop) []Tracer FROM TO DESCRIPTION(COIDr,hardness,sofl/rock tvpa grain size,etc.)
EiGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) 0 fit107 OVER BURDEN
2-7-2023 107fit• 185fit• GRANITE
4.Date Well(s)Completed: —Well ID#
5a.Well Location: q—!-j
Sean Tripi ft. ft.
FEU 2 7 2073
Facility/Owner Name Facility 1D#(if applicable) ft.
6 Grant Ridge Fairview NC 28730
ft. C=;=t, U I 0,�Physical Address,City,and Zip
Buncombe 967780513800000 Well Was Self Certified
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W 01/24/23
Signature ofCcrtifityW ell Contractor Date
6.Is(are)the well(s): RPermanent or Effemporary By signing this form,I herehv certify that the well(s)was(svere)constructed in areordance
ivith 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or ENo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information andexplaill the nature ofthe
repair under#21 remarks section or on the back qJ*thi.vJbrm. 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.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 225 —(ft.) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ij*different(example-3@1200'and 2(w.]00) construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water ResoiIrces,Information Processing Unit,
lj'-Awler level is above casing.use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY: Ila addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ROTARY 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 Ce;nter,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 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 helltti department of the county where
constructed.
FormGW-1 North Carolina Department of Environment and Natural Resources-Division of Water Res." Revised August 2013