GW1-2023-01943_Well Construction - GW1_20230227

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WELL CONSTRUCTION RECORD For Interval Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
Kolby Mitchell Sawyersr :, ::���� �� . •�_.....::,,v
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. 1
NC WellCoutractorCertificationNumber tS-OUTEtt= A ti toitiiirttieaseiltiCltS:t)I#11NEl3;ilF "" 6t
FROM TO DIAMETER THICKNESS MATERIAr.
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 56 ft- 6.25 in. #21 PVC
Company Name TG1}�NER1Ca(S#;. wtjttT,U1311G ""edflltsWsed=tiio' z
2022-00340 FROM 1'O DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: et. ft. in.
List all applicable ivell permits(i.e.County,State,Yariance,Injection,etc.) in.
3.Well Use(check well use): ;t 7S(1R1 •xi= ",`
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. I in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) > O oIUTI `;""```'`'
FROM TO MATERIAL EMPLACEMENT MF.TROn&AMOUNT
❑ln; ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
rt. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation ^I9 S17GItA>�ELPCI ifa"` clsb7` _'`'=
S yr ,.'s
FRODI TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. It.
El Experimental Technology ❑Subsidence Control
i2U "TiIC>T1IVT;tlt'.'a""toe'tiatlililSema"�sfie�'is`'�rfueeessari-'
❑Geothermal(Closed Loop) ❑Tracer FROI1[ TO DESCRIPTION color,hardness,soiltrock type. rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 56 rt• OVERBURDEN
TE
4.Date Well(s)Completed: 2-13-2023 Well ID# 56 ft' 205 ft GR—M�
g; ) Il'm '!l"yV P
5a.Well Location:
WESLEY FEIGHT ft. ft. t ; 2023
Facility/Owner Name Facility ID#(if applicable)
160 DOGWOOD ROAD CANDLER, NC 28715 ft. ft. Oi o`G}i0
Physical Address,City,and Zip RRh filth
BUNCOMBE 9607282505
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 CX 2-17-2023
Signature of Certifl e 1 Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
With I5A NCAC 02C.0100 or 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,Jill out knoxn well construction information and explain the nature of the
repair tender 921 remarks section or on the back oJ'thisJbrm. 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 supply wells ONLY with the same construction,you can
submit one fot•m. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface• 205 (ft.) 24a. For All Wells: Submit this'form within 30 days of completion of well
Far•multiple wells list all depths if dijferent(example-3 tit 00'and 2(tu100) construction to the following:
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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
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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.) l
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
m 13a.Yield
(gp ) Method 8 of test: RIG 24c.For Water Supply&Injection)Wells:
t ,
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount 20 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water R�sources Revised August 2013