GW1-2023-01947_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:
Kolby Mitchell Sawyers
FROM TO DESCRIPTION
Well Contractor Name
4471-A
NC Well Contractor Certification Number 'ISiitStlTRit'CkSiIY s(� fd"r`<IT cad w 7ls yOR LINER=iY+ii eatilc a<
FROM I TO DIAMETER ' THrCKNF,SS MATF.ATAT.
CLYDE SAWYERS & SON WELL & PUMP INC +1 155 rt 6.25 in. #21 PVC
Company Name IIVNER`iGAStIYG t)RfiUB71�G;"eotilerinh[rjose`d=10ti � s A .
2021-00640 FRONT '1'O DIAMETER 'THICKNESS MATERIAL
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): it7:iSCRELEN kk �"
Water Supply Well: FRONT TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Coolin Supply) EiResidential Water Supply(single) ft. ft. in.
� � g PPY) PPY( g )
❑IndustriaUCornmercial ❑Residential Water Supply(shared) FRONT TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hTi ation 0 ft' 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. tt.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater RemediationI9wAhYDiG
FRO51 TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft it
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
201iR1CI1NG1t1z ai aeliiddiflautii'slieetsf'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTTON color,hardness,soil/rock tv a gnin size,etc.)
❑Geothermal(HeatinglCooling Return) ❑Other(explain under#21 Remarks) 0 ft 55 ft OVER BURDEN
1-24-2023 55 ft 165 ft GRANITE
4.Date Wells)Completed: Well ID#
5a.Well Location: ft. ft. y
Jonathan Ray McCoy ft. fr. ` V ')'- ,r
Facility/Owner Name Facility ID#(if applicable) ft. ft. '�
111 Reeds Creek Road Fairview, NC 28730
Physical Address,City,and Zip
Ys Y P 3:1RE1V1ARKS��``.�+�"� �� `i``X�������, i '`:r.,.
Buncombe 9677800077 Well Was Self Certified
County Patel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
N W 01/31/2023
Signature of Ceutifi ell Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary
By signing this finrn,I hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC.02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No copy ofthis record has been provided to the well owner.
If this is a repair,fill out known Ncll construction information anti explain the nature of the
repair under#21 remarks section or on the back oj'this 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: 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 oneform. cG SUBMITTAL ESSTUCTIONS
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 ij'dijferent(example-3 d 00'and 2(ar100) construction to the following:
10.Static water level below top of casing:40 (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:1 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) 12 Method of test- RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: Amount: 20 well construction to the county health department of the county where
constructed.
Forst GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013