GW1--03516_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. fr.
4471-A ft. ft.
NC Well Contractor Certification Number 15'(ftlTEtt:CrSING far:rrtrlti caseilinrells"012�LINEBtE�a'1iEsblt
FROM TO DIAMETER THICKNFSS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 58 ft. 6.25 1 ! In #21 1 PVC
Company Name
t6,INNER CASING OR:TUBING '`fhereie[closed l04'
2023-00023 FRONT 1'O DIAMETER THICKNESS NIAT RIAI
2.Well Construction Permit#: ft. fr. in.
List all applicable a-ell pennits(i.e.Cougv,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17..SCREEPT-
Water Supply Well: FROM TO DIAMETER SLOTSIZE I THTCKNESS I MATERIAL
tt. ft.❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) E IResidential Water Supply(single) tt. fr. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&.AMOUNT
❑li,; ation 0 rt. 20 ft- Bentonite Pumped
Non-Water Supply Well:
rt. rt. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 29.aSANDi(,RAEL°PAG❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO ft. MATERIAL EMPLACEMENT 51ETHOD
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
:20 DRILLT1t1�s�OG-"attach'addifiuQalsheets'ifnecessa'r`v,_ :.::.... �`------..
❑Geothermal(Closed Loop) ❑Tracer FRONT TO DESCRIPTION color,hardness,soilfwk type. rain size,etc.)
❑Geothermal Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 ft 58 ft OVER BURDEN
4-26-2023 58 rt 145 ft GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
John Eldreth
Facility/Owner Name Facility ID#(ifapplicable) ft. fr• MAY1 Q lOZ3
Long Ridge Rd., Candler ft. f.
Physical Address,City,and Zip
Buncombe 8695-53-1907
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 «, C. 4-27-2023
y7aN I ;IQ
Signature ofCerlifi ell Contractor. Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this form,I herehv certify that the well(si w'us/were)constructed in accordance
with 1 sA NCAC 02C.0100 or 1 SA 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 been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 921 remarks section ur on the back of this form. 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 ityection or non-water supply wells ONLY with the same construction,you can
submit one form. 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 iJ'diJJerent(arample-3@200'and z(a l00) construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,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: 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:
PILLS Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: Amount• 35 well construction to the county hei Ith department of the county where
constructed.
Fong GW-1 North Carolitia Department of Environment and Natural Resources—Division of Water Resources Revised August 2013