GW1--04552_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 A4 wATER2rrl o °.gamm., --,,-aamwe
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number GASIIY{ {foi tnuId easCd;n i tt5};,(}R.'t INER(lk>a p idab[c} # �
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 It. 62 ft• 6.25 #21 PVC
Company Name 1f%INNER')CASfI Oitorl:iB111Gi(Qtrother`ritatclosed-fpo , : i*�,' x s
2023-00193 FROM DIAMETER THICKNESS MATERIAL2.Well Construction Permit#: fL ft. in.
List all applicable well permits(i.e.County,Slate,Variance,Injection,etc.) ft ft. in.
3.Well Use(check well use): r
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Publie ft. ft. -
in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) #i8 GROUT , :W a, :<r ,r, ,,, =40 1 M
FROM TO MATERIAL EMPLACEMENT METHOD)&AMOUNT
❑h,;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 SAND/GRAZ'EL EACK"(it apliliriitite)xaX;rixa4MM� a
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery El Salinity Barrier •
ft, ft.
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
DExperimental Technology ❑Subsidence Control
k20:DRILLINGIOG{a"ttacti'.nddrt)auaLsheetsiEiaiiiiir'vj61.~.K :7
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size.etc.)
❑Geothermal(Heating/Cooling Return) ID Other(explain under#21 Remarks) 0 ft. 62 ft. OVER BURDEN
05/30/2023 62 ft' 185 ft• GRANITE
4,Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
Kayla Wells ft. ft. _
Facility/Owner Name Facility ID#(if applicable) ft. ft.
8 Arda Drive, Candler 28715 ft. JUL I 2323
Physical Address,City,and Zip
Buncombe 86878348110000 ftIREVIARks �.= . vS14 . . l ViI . s
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 06/16/2023
Signature of Certifi ell Contractor Date
6.Ts(are)the well(s): OPermanent or ❑Temporary By signing this farm,I hereby certify that the well(s)was(were)constructed in accordance
with I5A 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 ElNo copy of this record has been provided to the well owner.
If this is a rapair,fill out known well construction information and explain the nature of the
repair under#21 remark•section or on the hack 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: 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//)200'and 24100') 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 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: constriction 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) 50 Method of test: RIG 24c.For Water Supply&InjectionWells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount 2O well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013