GW1--04548_Well Construction - GW1_20230713

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers Afel, *ATERIONE8 ` , v' . ,' ,
.sue .
FROM TO DESCRIPTION
Well Contractor Name ft ft. j '
4471-A ft. ft.
15 dt1'l'.ERtCA8IN jforinufd ii4t1iiieltifeitiLiNER'(i ii plicalik). ', VS
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 It' 72 ft• 6.25 in. #21 PVC
Company Name 1I631NIV$R.CASIN, ORTtlBIMsI "`" vsed-1oop—. '
2022-00444 FROM TOl)IAMEI'F.R 'THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 11547.9SCREEN. :::7'' �.�', `° fi. : %Vjlg `
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Publie
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
1R.`GR()UT O- lMC1;x10-1: z ;..z'yf' n' '�a.r AIrl:
❑IndustriaUCommercial ❑Residential Water Supply(shared) FROM TO ' MATERIAL EMPLACEMENT METHOD)&AMOUNT
❑in;gation 0 ft. 20 ft' Bentonite Pumped •
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft. Cap Top with Bentonite Chips
injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19 SAN1i/GRA1?ELI'ACV(il'applical lej f»' k :.<. ., .=, '` ,,
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
DAquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20 7)MILLING T'001tiftichradditiiiiinf heels if necessary) sue,✓ 'a^
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 72 ft. OVER BURDEN
5-31-2023 72 ft• 185 ft. GRANITE
4.Date Weil(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft. R t.�� i i f P lJ
Dennis Ivanor ft. ft.
Facility/Owner Name Facility ID#(if applicable) JULft. ft. � 2023
J
199 Montecello Road Weaverville 28787
ft. ft. Intow1:L+ D ter: r:<! 111)3"Z'
Physical Address,City,and Zip s� ^*gatlia;li
Buncombe 9732497973 ZtRENlRKS>:M ,
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 W 6-5-2023
Signature of Cettifi ell Contractor Date
6.is(are)the well(s): ❑O Permanent or DTemporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or IF1No copy of this record has been provided to the well osrwer.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remark section or on the back of this.limn. 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 if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 1 85 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(at200'and 24;100') construction to the following:
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 20 (ft)
'Pinter level is above casing.use"+" . 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY: In addition to sending the font 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
RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 20 Method of test:
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.
Fora)GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013