GW1-2023-01946_Well Construction - GW1_20230227

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This lbrm can be used for single or multiple wells
r
I.Well Contractor information:
KOlby Mitchell Sawyers F4.WATERZONES
FROM TO DESCRIPTION
Well Conti-actor Name
ft. ft. ('
4471-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a able)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 140 ft. 6.25 in. 1 #21 PVC
Company Name l6.INNER CASING OR TUBING.(eothermal closed400'
2021-00491 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. i in.
List all applicable well permits(i.e.Couuy,State. Variance,Injection,etc.)
ft. ft. j 'in.
3.Well Use.(check well use): 17.SCREEN
Water Supply Well: FROM 110 DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) FIResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft- Bentonite Pumped
Noll-Water Supply Well:
ft. ft.
❑N,lonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL' EMPLACEMENTMETHODft. ft.
❑Aquifer Test ❑Stonnwatcr Drainage
❑Experimental Technology ❑Subsidence Control
20.DRiL;LING LOG attach addit3onaTshee[s if necessar
❑Gcothennal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
❑Gcothennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1 0 ft. 40 rt. OVER BURDEN
12-3-2022 40 ft• 445 ft• GRANITE
4.Date Well(s)Completed: Well ID#
ft. rt.
5a.Well Location: ft. ft. r: -4 +
Andres Manniste �
ft. rt.Facility/Owner Name Facility iD#(ifapplicable) FUR 7 2923
ft. rt.
132 Saddle Ridge Alexander, NC 28701 ft. ft. Infon7ttla-;;Dn Pr c*aggsnj Ur,,,i
Physical Address,City,and Zip 21.REMARKS
Buncombe 97128899780000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(itwell field,one tat/long is sufficient)
N W 01/4/2023
Signature ofCcrtificy Well Contractor i, Dale
1.
6.is(are)the well(s): R Permanent or ❑Temporary Br signing this forth,I herebv certJv that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy gfthis record has been provided to the well owner.
U'dnis is a re pair,fill out knoun well construction infimnation and explain the nature of the
repair under#21 remarks section or on the back of this firm. 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-Crater supply wells ONLY with the saute construction,con can
sahmit once Jornn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 445 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Fnr nwhiple wells list all depths f1'd4Jerent(example-3@200'and 2@/001) construction to the following:
I
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
Ill rater 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
(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
13a.Yield(gpm)4 Method of test• RIG 24c.For Water Supply&In,jectionl Wells:
PILLS C Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 35 well construction to the county health department of the county where
constructed. i
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fu me(iW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013