GW1--03512_Well Construction - GW1_20230519

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 ft. ft. j
4471-A «•
NC Well Contractor Certification Number 15:0LITE CASING forninld cased wells OR'a,INER'_I,"
hcable'> ..:.
FROM TO DiAM1•TF.R THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 158 rt. 6.25 in. #21 PVC
Company Name [d;tiViY£R C 1$iNG l)R CUBING `eofhecmil:slo5¢tf=too --,�s a
2023-00023 FROM to DIAMETER 'THICKNESS NIATERI.AL
2.Well Construction Permit#: ft. ft. in.
List all applicable Hell permits(i.e.County,State,Parlance,Injection,etc.) ft ft. in
3.Well Use(check well use): t7 SCREL>V .
Water Supply Well: FROM TO DIAMETER I SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal (Heating/Cooling Supply) ®Residential Water Supply(sin(single) ft. ft. in•
❑IndustriaUCommercial ❑Residential Water Supply(shared) E
FROM TO MATERIALL FMPLACMFNT METHOD K AMOUNT
❑Titi ation 0 ft' 20 ft. Bentonite Pumped
Non-Water Supply Well:
rt. rt. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation %1SANDIGRtAVEL-PAC#£-tfa `cable .
FRO5I TO MATERIAL EDIPLACEMENT 5IETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20A)RILLING O3,attach additioiiat.iheets:ifitecessary;.....
❑Geothermal(Closed Loop) ❑Tracer FRONI TO DESCRIPTION color,hardness,soilliwk type. rain size,etc.)
❑Geothermal(Heating/Cooling Return) []Other(explain under#21 Remarks) 1 0 ft- 58 ft. OVER BURDEN
4-26-2023 58 ft 145 ft GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: «. ft.
John Eldreth ft. «. .•. "
Facility/Owner Name Facility ID#(ifapplicable) ft � E
, ft. N
Long Ridge Rd., Candler ft. MO
Physical Address,City,and Zip
21:REMARKS
Buncombe 8695-53-1907 m. W..
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one]at/long is sufficient)
N `,1t 4-27-2023
Signature ofCertifi 0ell Contractor Date
6.is(are)the well(s): RPermanent or ❑Temporary By signing this form,1 hereby certify'thut the well(,)was(were)constructed in accordance
with ISA NCAC.022C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No copy of this record has becti provided to the well owner.
If this is u r(�pair,frll ont knuwu well cumtructiwr info-mution and espluiif die nature of the
repair under 921 remark,,section or on the back ofthis jirrm. 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 sume construction,you can
submit one farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 145 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd(ffierent(c«ample- dj200'and 2(a,100) construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
Ij'water level is above casing.use"+" 1617 Mail Service Center,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
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) 20 Method of test: RIG
24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type. PILLS Amount: 35 well construction to the county health department of the county where
constructed.
I '
Fortis GW-1 North Carolina Department of Environment and Natural Resources--Division of Water Resources Reused August 2013