GW1-2023-01948_Well Construction - GW1_20230227

WELL CONSTRUCTION RECORD For Interval Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kol by Mitchell Sawyers F4��, DESCRIPTION
FROM TO DESCRIPTION
Well Contractor Name
4471-A
NC Well Contractor Certification Number
lSu'iOU PEtt'@AStf+tr fii'r.`iriidtl=ciiseil.neiis:`;t7it'l r>VER it's""iicutite y:,x?
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. 70 ft- 16.25 i #21 PVC
Company Name 'A 4.11 N NE[2``CXSING",0 tT,USI Cs' eu'tli�rmat ctose'i1 too " g��� � "'ce`
2022-00183 FROM DIAMETER ER THICKNESS MATERIAL ?kY
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Yariatce,bjcction,etc.) ft. ft. in.
3.Well Use(check well use):
n��.��1YFx�1� aliJ,•�+A•;,�;:.`:�'.n���.,�".-:".x``ir'.� .,���5_R`':rkti:''.:;�%'�:''.?£.� Yz�:`:�y� �'����,
Water Supply Well: FROM TO DIAMETER SLUT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. it. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM TO xMATERIAL EMPLACEMENT METHOD&AMOUNT
❑b,; ation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ,9V,$ANbA;RAiV
❑Aquifer Storage and Recovery ❑Salinity Barrier FRODI TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. f1.
❑Experimental Technology ❑Subsidence Control
I2It11�GTOG:ia2taeli'ildihvitasheet`sifneces`siirv` �
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrmk tv a grain size,etc.)
❑Geothermal(Heatin Cooling Return) ❑Other(explain under#21 Remarks) 0 fr' 70 fr• OVERBURDEN
10-28-2022 70 fr, 205 fr• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: �- y,�• r
ft. ft. 'c 14.,..'�,,,,D N•..,..5 16v �l..e.
Juan Mandujano ft. ft.
Facility/Owner Name Facility ID#(if applicable) FEB 2 P 2023
23 Three Dove Lane Candler, NC 28715
Physical Address,City,and Zip ;- -
r5i I!,.,,',47,P
Buncombe 86965019460000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certitication
(if well field,one lat/long is sufficient)
N W 2-7-2023
Signature of certif Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary y b 3 f fy` (1 (were)B si otin�this orm,1 herein•rein tlrcd the wells was were ronstruc/ed in accordance
+rith 15A NCAC 02C.0100 nr 1 sA NCAC 02C.0200 14 ill Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided to the well owmer.
If this is a repair,fill out known well construction in rmation and explain the nature of the
repair under#21 remarks section or on the brick t f 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
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple it jec•tion or non-water supply wells ONLY with the suene construction,you can
submit ore form. 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
For multiple wells list all depths iij ciffferent(example-3(+200'and 2(ayl00') construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
If utter level is above casing.use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY:i In addition to sending the form to the address in
ROTARY 24aabove, also submit a copy ofltltis form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.anger,rotary,cable,direct push,etc.)
Division of Water Resources;Underground Injection Control Program, qf.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 1?
13a.Yield(.-pm) Method of test: RIG 24c.For Water,Supply&Injection Wells:
PILLS �I Also submit one copy of this folin within 30 days ofcompletion of
13b.Disinfection type: 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 ofWater Resources Revised August 2013
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