GW1--04549_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 14AYA1'I✓R:ZONEs„ . ,t 1 ,; 1:r
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number „I5,DUTER=CASING(for multi-eased Wells)`OR LINER tif- nnlicable) .t;;,
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 25 ft. 6.25 #21 Pvc
Company Name ;16.INNER�CASING ORTi BIND:(geOfhe"rmbt closed tooµ} t
2023-00081 FROM TO DIAMETER 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):
17,-'SC REEL _ _ _k 4 ,.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.,
❑Geothennal(Heating/Cooling Supply) EResidential.Water Supply(single) ft. ft. in•
❑industrial/Commercial ❑Residential Water Supply(shared) f8:'C ROUT . ; 8 ,. "
FROM 'ro MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Urigation 0 ft. ft
Non-Water Supply Well: 20 Bentonite Pumped
OMonitoring ❑Recovery ft. ft. Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation =I91-SAND/GRA LPACl((ifapplicahte) ..,. �4:
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
30s1)ttILL'Iti ;IOCr.(attackaddltlobriatsheets;if iecessal}}=2
❑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• 25 ft• OVER BURDEN
6-1-2023 25 ft• 205 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft. _ Fj 'h a_F 3 f—t
Tara Hochstein ' -n. ,Y.• ° V E
ft. ft. ,
Facility/Owner Name Facility 100(if applicable) ft. ft. JUL 1023
179 Louisiana Ave ft. ft.
Physical Address,City,and Zip �nfn !t'il f1)' .yf�,,, Lrf.µ
Buncombe 9638262971000 21:RZ MARFt�i { q r ct„cn '. ,< ,�_ ;.
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 06/05/2023
Signature ofCertifi Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary
By signing this jbrm,1 hereby eel.*that the well(s)was(were)constructed in accordance
with ISA 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 DNo copy of this record has been provided to the well owner.
If this is a repair,.fill out known well constrtiction information and explain the nature of the
repair under#21 remarks section or on the back of this fora. 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: 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 farn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a)200'and 2@l00') construction to the following:
10.Static water level below top of casing: 30 (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 injection 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.) 1
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) 5 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. 1
Form OW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013