GW1-2023-02769_Well Construction - GW1_20230417

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
1,
Kolby Mitchell Sawyers 44RMATIR ZONES
FROM TO DESCRIPTION
Well Contractor Name
4471-A
NC Well Contractor Certification Number FROM TO DTAMETER_ THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 56 tit 6.25 in. #21 PVC
Company Name _116.ANNER`C ft .
ernift e
2.Well Construction Permit#: 2017-00556 FROM ft. TO ft. DIAMETER in. THICKNESS MATERIAL
List all applicable well permits(i.e.County,State,Yariance,Injection,etc.) in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS I NIATERLU
DAgricultural []Municipal/Public in.
DGeothermal(Heating/Cooling Supply) EIResidential Water Supply(single) in.
Olnduqtrial/Commercial oResidential Water Supply(.shared) '.FROM
OUT TO MATERTAL EMPLACENTENT MET•HOI)&AMOUNT
EITnigation 0 ft' 20 ft- Bentonite Pumped
Non-Water Supply Well: ft. Cap Top with Bentonite Chips
ElMonitoring ElRecovery
Injection Well: ft.
ElAquifler Recharge ElGroundwater Remediation
`M' I ­­' 1 .1
DAquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT 51ETHOD
0Aquifer Test OStorinwater Drainage
ElExperimental Technology OSubsidence Control
a("i"N'I
DGeothermal(Closed Loop) Effracer FROM TO DESCRIPTION(color.hardness,soillreck type.grain size.etc.)
OGeothennal(Heating/CooHng Return) 00flier(explain under#21 Remarks) 0 ft 56 ft OVER BURDEN
4.Date Well(s)Completed: 2-15-2023 Well ID# 56 485 GRANITE
ft.
5a.Well Location: ft. ft.
Dana Lovett
Facility/Owner Name Facility ID#(if applicable) APR 1 2023
42 Holly Ridge Candler, NC 28715 ft. ft.
Physical Address,City,and Zip
74 7K 5
Buncombe
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N Won01— 2-27-2023
Signature of Ccilifi ctor I Date
6.Is(are)the well(s): PIPermanent or OTemporary By signing this form,I hereb'v'certffy that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well; C]Yes or ©No copy of this record has been provided to the well outer.
If this is a repair,fill out knon7i well construction information and explain the nature of the
repair under#21 remurAw section or on the back efthisfiorm. 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 if necessary.
For multiple injection or non-water supply svelly ONLY wide the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:485 —(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iftifflerent(example-3@)200'anil 2@100� construction to the following:
10.Static water level below top of casing: 80 (ft.) Division of Water Resources,Information Processing Unit,
1J*m%uer 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
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) 2 Method of test- RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this for I m,within 30 days of completion of
PILLS Amount: 35 well construction to the county health department of the county where
13b.Disinfection type: constructed.
Form GW­I North Carofina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013