GW1--04551_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 4 OS�i1rlER01YEs
FROM TO DESCRIPTION
Well Contractor Name ft. ft. 1 '
4471-A ft. ft. .
NC Well Contractor Certification Number 15;:O.rttttr`AStNG(farinattleu8i veltnitaR+LIIYC ifi*ticstite} s. .. ...-
FROM TO DIAMF,TF.R THICKNESS MATF.Ri.AL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 78 ft. 6.25 in• #21 Pvc
Company Name 1&IIyNER CASING ORTUBJNOlke'GtheriiiitUdosetl-h,p) .-.,, .. ...
2022-00184 FROM '1'0 DIAMETER THICKNESS MATI:RIAI.
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,Slate,Variance,injection,etc.) ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single)
ft. ft. in.
� !� g PPY) pPY( g
❑lndustriallCommercial ❑Residential Water Supply(shared) 18' t1UUT
FROM TO MATERIAL FMPLACF,MFNT METHOD&AMOUNT
❑hrigation 0 tt• 20 n• Bentonite Pumped
Non-Water Supply Well: ft. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.'SANDWORAYELr PA (ifapplt'cubley-..___._ M-. .- -_M
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stotmwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
2U bR11;f0G LOG(attaeL.additiai atslieets:ifjtecessary) -,
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soilrock type.gram size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 78 ft• OVER BURDEN
6-8-2023 78 ft. 405 ft• GRANITE
4.Date Well(s)Completed: WellID# ft. ft. r--' t-.,; fr
5a.Well Location: ft. ft. , 'b"°""�:Y" 'e ?,�
Mohar C Thakuri ft. ft. JIJI 1 el 2023
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
Beaverdam Forest Info ,..,, . ;: j Ui,.;
ft. n DM/3-t
Physical Address,City,and Zip .2L 11EINARI ,, ,�,
Buncombe 9750572414 This 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 W 06/08/2023
Signature of Certifi ell Contractor Date
6.Ts(are)the well(s): OPermanent or ❑Temporary By signing f /j (j (were)si min•this nrm,1 hereby certt that the well(s)was were constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided to the well owner.
If this is a rrpair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this 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 construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if'dtj/ferenl(example-3(aj200'and 24,100) 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 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
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.
Fern GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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