GW1--04554_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 Sawyers '.14.R TO S, -. ..ass. . :i,�xLlt�z(�
FROMDESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft. -
NC Well Contractor Certification Number <t3:-OUTEft CASING(for"multl casedifs)ORLINEtt.(ifappiteatite):
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 it. 106 ft• 6.25 #21 PVC
Company Name t6;INNER CAStNG.OR;'f`UBING,(kafheifikel erased-IdoP)`.. -..:
2021-00035 FROM 10 DIAMETER 'THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well pennits(i.e.County,State,Variance,Injection,etc) ft it• in.
3.Well Use(check well use): f7.:SCREEN... :E, . .
Water Supply Well: FROM TO , DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) laResidential Water Supply(single) ft. ft. - in.
❑lndustriaUCommercial ❑Residential Water Supply(shared) --l8.GROUT .-.-6.v„�. --- -
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑TrTigation 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 29,:SAND/ORAVELLrACK(ifapgh'oableL .- - a
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stonnwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control 20`DRILLINGLOG(attaeh addition islteets'idneeessarv)-:
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION(color,hardness,soil/rock type,grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 106 ft• OVER BURDEN
4.Date Well(s)Completed: 05/10/23 Well ID# 106 ft 605 ft. GRANITE
ft, ft.
5a.Well Location:
ft. ft.
Ilse,K..". , ...-
Alfonso Socarra ft, ft. �,1 a a':. t. I
Facility/Owner Name Facility ID#(if applicable) ft, ft.
Concord Rd., Lot 3 it. ft. JUL 1 ` 2u2J
Physical Address,City,and Zip
Buncombe 9674473771 .21.REMARKS�t :._,,, � ^�r... ��� sri L.,1....
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certilic 'on:
(if well field,one lat/long is sufficient)
N W 06/20/2023
ignature of Well Contract Date
6.is(are)the well(s): OPermanent or ❑Temporary
By signing this firm,I hereby certfy that the we/l(s)was(were)constructed in accordance
with 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo copy of this record has been provided to the well owner.
If this is a rpair.fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the hack 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
S.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: 605 (ft.) 24a. For All Wells: Submit this form within 30 days.of completion of well
For multiple wells list all depths ifdijjerent(example-3(aj200'and 2(000') 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.)
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) 2 Method of test:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 30 well construction to the county health department of the county where
constructed. I
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013