GW1-2023-01949_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 4PA'ATERiZ0NE$FRO51 TO DESCRIETION
Well Contractor Name ft. ft.
ft.
4471-A ft.
NC Well Contractor Certification Number 34#yo tatPOICAS W*106 rliw6fdrefi"11 Qfilrowll ON OR
FROM TO DIAMETER 1 THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 't- 46 ft- 6.25 in. #21 PVC
Company Name
FRO1%I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 2022-00552 ft. ft. in.
List all applicable vivIlperinits(i.e.County,State,Variance,Injection,etc.) in.
3.Well Use(check well use):
Water Supply Well. FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
ft. ft. in.
DAgricultural CMunicipal/Public
DGeothermal(Heating/Cooling Supply) EgResidential Water Supply(single) ft. ft. in.
01ndustrial/Commercial DResidential Water Supply(shared) ACGROUT,#000%
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Ellnigation 0 20 ft- Bentonite Pumped
Non-Water Supply Well:
OMonitoring ORecovery
Injection Well; ft. ft.
DAquifer Recharge []Groundwater Remediation 019J4SANWGRAVVn__TEVP 'fit
0Aquifer Storage and Recovery OSalinity Barrier FROM ft. I TO MATERIAL E51PLACEMENT METHOD
DAquifer Test 0 Stormwater Drainage ft. ft.
0 Experimental Technology DSubsidence Control 74-05-mill-CEO RaAc adaittkawww-niri"
ElGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soill o k typa grain size.etc.)
OGeothermal(Heating/Cooling Return) 00ther(ex lain under#21 Remarks) 0 46 ft OVER BURDEN
1-20-2023 46 ft 305 GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location:
CMH Homes ft. ft. FER 9, 7
Facility/Owner Name Facility ID#(if applicable) ft. ft. I -
45 Wiggle Worm Drive Fairview, NC 28730- ft. ft. ?rc�c3owng Untl
I "LLRINM
Physical Address,City,and Zip
Buncombe 968699595300000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lattiong is sufficient)
N W 2-1-2023
Signature ofCcitiflywell Contractor Date
6.Is(are)the well(s): [OPermanent or OTemporary By signing this firm,I hereby certify that the well(s)was(were)constructed in aceordance
with 15A NC,4C 02C.0100 or 15A NCAe 02C.0200 01,11 Construction Standards and that a
7.Is this a repair to an existing well: OYes or E]No copy of this record has been provided to the well owner.
If this is a rcepair,fill out knomi well construction information find explain the nature of die
repair trader#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
S.Number of wells constructed: 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 form. SUBMITTAL INSTUCTIONS.
9.Total well depth below land surface: 305 —(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if'elfffierent(erample-3@1200'and 2(a100) construction to the following:
10.Static water level below top of casing: 20 (ft) Division of Water Resou'rees,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: i•In 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 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 20 Method of test- RIG 24c.For Water Supply&Injection1wells:
Also submit one copy of this form' within 30 days of completion of
13b.Disinfection type- PILLS Amount: 30 well construction to the county health department of the county where
constructed.
FormGW­I North Carolina Department of Environment and Natural Resources—Division ofWatcr R6sources Revised August 2013