GW1--05591_Well Construction - GW1_20240916

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WELL CONSTRUCTION RECORD For Internal Use ONLY: I'
This form can be used for single or multiple wells
1.Well Contractor Information: '
Derrick Heath Sawyers of Io . � � . m,�i F,.. ;. !;
FROM TO DESCRIPTION
Well Contractor Name ft, ft,
2436-A ft. ft. I
NC Well Contractor Certification Number #15,T`Ol1 gRV S1 D tfot ritultl eniVii}};eltsy.Oltxl t t1;teftenpiii1a0tc) '`* _°' .'
FROM TO DIAMETER THICKNESS MATERIAL.
CLYDE SAWYERS & SON WELL & PUMP INC +1 tt. 68 il• 6 1/8 f:in• #188 STEEL
Company Name tf1ttiANISi~ttGt151NG tet1`l)Bl}is"( FlntruiaCclosed toUP) '. :W I'0, is '" '
WEL2024 0313 FROM TO DIAMETER THICKNESS stA'1'N:RL41.
2.Well Construction Permit#: ft. ft. ' in.
List all applicable well permits(i.e.County.State,Variance,hjection,etc.)
ft. ft, ', in,
3.Well Use(check well use): 3MSG`I;BENt <;.' a' , ;r `r1 ac ,: MRC,, %AiM1
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ElResideutial Water Supply(single) ft. ft. in.
❑industrial/Comn)ercial [Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&.AMOUNT
_❑Tn gation 0 ft• 20 ft• Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft. Cap Top with Bentonite Chips
injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation 14 SAND/GItM L Y.AGK'(inpltlic)11t18), ,iVeJjK MiVatir;W..,I s%lu
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery ❑Salinity Barrier ft. ft.
DAquifer Test ❑Stonnwater Drainage ,
ft. ft.
DExperimental Technology ❑Subsidence Control
r2(i 11tICI 1 0V.0 ,taC'ta liiii latioi¢al3ltce ilti ccessarv'j � rig
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
O Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 68 ft• ; OVER BURDEN
8-13-2024 68 ft• 305 ft• GRANITE
4.Date Well(s)Completed: Well ID#
ft, ft. I
ttr
5a.Well Location: ft, ft. 1N. i.,.. /,
LINDA EDWARDS ft. ft. is
SEP ?(,
Facility/Owner Name Facility ID#(if applicable) ft. ft. II L V 24
11 SIMPLICITY LANE SWANNANOA, NC 28778 tt ft. i rrw$� u �
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Physical Address,City,and Zip 2.1:r1t.EN101(S 0'i `W2X114 MVP :47.`. 4.Viir,W`t
Buncombe 968834029800000 WELL WAS'SELF CERTIFIED
County Parcel Identification No.(PIN) I;
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
_ - 8-19-2024
N W 1 .1;--. ���
Signature of citified Well Contractor Date
6.is(are)the well(s): ❑�Permanent or ❑Temporary By signing this firm.1 herehr certify thatdhe wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
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7.Is this a repair�; to an existing well: ❑Yes or ❑No copy of this record has been provided to the.we//owner.
If this is a repair.fill out known well construction information and explain the nature of the I
repair under 421 remarks section or on the hack of tirn,,. 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_ ii
9.Total well depth below land surface: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iildilJerent(crumple-3(a1200'and 24;100') construction to the following: ji
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10.Static water level below top of casing: 80 (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: Ili 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
(i.e.auger,rotary,cable,direct push,ctc.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
4 RIG 24c.For Water Supply&Injection W Ills:
13a.Yield(gpm) 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.
Fort OW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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