GW1-2023-01952_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:
' ' AW ,ITWZ0?MSt 4 M­ �N_M
Kolby Mitchell Sawyers M4�FROM TO DESCRTPTTON
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number tiT EK-V'm Mjwt&r
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 �ft 87 ft- 6.25 ; in. #21 PVC
"
"6ANN f W4019(11T
Company Name 'M EC
FROM DIAMETFR THICKNESS MATERIAL
2.Well Construction Permit#: 2022-00386 ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. in.
3.Well Use(check well use):
Water Supply Well: FROrst TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
L
DAgricultural DMuriticipal/Public in.
ElGeothermal(Heating/Cooling Supply) ElResidential Water Supply(single) in.
Olndustrial/Commercial DResidential Water Supply(shared) fls;,.GRou',r0
FROM TO MATERTAL ENTPLACENTENT METHOD&AMOUNT
ElInigation 0 20 ft- Bentonite Pumped
Non-Water Supply Well:
OMonitoring DRecovery
Injection Well:
0Aquifer Recharge DGroundwater Remediation
OAquifer Storage and Recovery 0 Salinity Barrier FRO51 TO MATERIAL E51PLACEMF-NT METHOD
0Aquifer Test OStormwaterDrainage ft. ft.
OExperimental Technology OSubsidence Control
,40DRICLINO-10 iieh`ichfiffia6141kits it, gkil 10 1 !T M -W y _WW"
DGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soitlrock type.grain size,etc.)
OGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) 0 fL 87 R OVER BURDEN
4.Date Well(s)Completed: 12-22-2022 Well ID# 87 265 GRANITE
_4
5a.Well Location: rt. ft. v tJis,-
Brandon Hensley
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Bear Creek Lot 1 Leicester, NC 28748 ft. ft. ln4oi`A-,ziAs_"n i1rz.n.5n!Fj Ur,r
Physical Address,City,and Zipri,t �aa -M"
Buncombe 97113086240000
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 2-9-2023
Signature ofCcitiflywell Contractor f Date
6.Is(are)the well(s): 21'ermament or ElTemporary By signing this form,I hereky certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200;1'ell Comm action Standards and that a
7.Is this a repair to an existing well: OYes or F]No copy ofthis record has been provided to the well o%7Zci-.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 921 remarE,section or on the back ofthisfirn). 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 ifnecessary.
For multiple byection or non-water supply wells ONLY wilt the sumo construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 265 -(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ty'ditfii-en t(example-3(a,)2 00'and 2(cu10 0) construction to the following:
I
10.Static water level below top of casing:.20 -(ft.) Division of Water Resources,Information Processing Unit,
Jfsi vier level is above casing.use"+" 1617 Mail Service 6.nter,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection Wells ONLY: '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) 15 Method of test- RIG 24c.For Water Supply&InjectionWells:
Also submit one copy of this formwithin 30 days ofcompletion of
13b.Disinfection type: PILLS Ainount: 20 well construction to the county he-.,Itl department of the county where
constructed.
FormGW­I North Carolina Department of Environment and Natural Resources-Division of Water R8sources Revised August 2013