GW1--03515_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 FRO51 TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft.
NC Well Contractor Certification Number 7E5 O TER,t ASiNG-io"r."ti""ultl eased Hells:OR LINER iY's Iteable z k,:""'
FROAf TO DIAMF.TF.R TAICKNF,SS A[ATF.RTAT,
CLYDE SAWYERS & SON WELL & PUMP INC +1 It. 102 ft- 6.25 in #21 PVC
_ r.K. r��_ ; ,�.,
Company Name NI6INiVR°CASt1YG�R;tttBlN eptberme[cIosed-too"
2022-00399 FROM TO DIAMETER 'rnICKNMSS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable uvil permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in,
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in,
130GR0III
❑IndustriaUCornmercial ❑Residential Water Supply(shared) FROM TO MATERIAL FATPLACEMF.NTMF.THOD&AMOUNT
❑irri ation 0 20 ft- Bentonite Pumped
Non-Water Supply Well:
rt. It. Cap Top with Bentonite Chips
❑Monitoring []Recovery
Injection Well: tt• ft.
❑Aquifer Recharge ❑Groundwater Remediation 749 SXWVIGRAVELVAtwWifii"
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHODft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
�2UY}1t1LT:119Ct`I�VGta`tiacri=ailolt�u'zsfTeels't' etv��" � ��w"
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rmk tv a gnin size,etc.)
❑Geothermal (Heating/Cooling Retum ❑Other(explain under#21 Remarks) 0 ft, 102 tt OVER BURDEN
4-19-2023 102 rt• 185 ft• GRANITE
4.Date Wells)Completed: Well ID#
tt. tt.
5a.Well Location:
Erica Williams U-` V
ft. ft.
Facility/Owner Nance Facility ID#(if applicable) ft. ft. MAY
Selby Drive Leicester, NC 28748 ft.
Physical Address,City,and Zip
Buncombe Well was self certified
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 `,ir 4-20-2023
Signature ofCcrtiflifWell Contractor Date
6.is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,I herehv certify that the well(s)ivas(were)constructed in accordance
with 15A NCAC 02C.0100 nr I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an eidsting well: []Yes or ❑No copy ofthis record has been provided to the well owner.
If this is u repair.fill out knouw well construction information and explain the nature of the
repair under#21 remarb-section or on the back oJ'1his firm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same coustruction,you can
submit one form. p C SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ij't4ffierent(example-3 dI 00'and 2(a,100D construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
If rater 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) 8 Method of test: RIG
24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 20 well construction to the county health department of the county where
constructed. I
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013