GW1--06699_Well Construction - GW1_20241108

WELL CONSTRUCTION RECORD For Internal Use ONLY: }
This form can be used for single or multiple wells _
1.Well Contractor Information: -:
• Derrick Heath Sawyers Y FROM TO DESCRIPTION
Well Contractor Name ft. ft. I ,
2436-A ft. ft.
NC Well Contractor Certification Number i5 OtSFERCASING(roc tnultrcasediwells)OR:iI INER{if appltcable); ..
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS &SON WELL & PUMP INC +1 ft. 60 . ft. 6.25 1"• #21 PVC ••
Company Name 16:INN£R:CASING OR"TUBING{geothermal.etoted Ioo(f)> ,5 ,,
2024-00021 FROM '1'O DIAMETER THICKNESS MMA ERIAI.
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"SCREI :i•:
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) 1Residential Water Supply(single) ft. ft. in.
❑lndustriaUCommeicial ❑Residential Water Supply(shared) '1S.GRotJT .�.. -. .• =:
FRODi O`� ATF.RiAL FMPLAF.MFNT MRTFiOD&ANOUNT
❑i rigation- 0 ft• 20 - ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft. • Cap Top with Bentonite Chips
❑Monitoring • ❑Recovery •
injection Well: • • ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/GRAVEL`PACK'(if:applicabley... :
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery 0 Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage ;
ft. ft.
❑Experimental Technology • 0 Subsidence Control
ZOt URTLIING:2:OG(attae&:additio¢a1`sheets:ifaiecessarv).W,. ,<�: ....
❑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. 60 ft. OVER BURDEN
09-24-2024 Well ID# 60 ft. 585 . ft. ;.--OMNITE^__ ,
4.Date Well(s)Completed: ft. ft. ``,' -
5a.'Well Location: ft. ft. .'
Edward Weiss ft. ft. NOV v-v .2024
Facility/Owner Name Facility ID#(if applicable) f. ft. ')-nr r
Pisgah View/St. Bernard LN., Candler ft a i�°a":.r�rit.a,�<,� t� �
j
Physical Address,City,and Zip 421 REMARKS
Buncombe • 8685218614 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) -
W14 S` 10-18-2024
. Signature of ertified Well Conti-ado •• Date
6.is(are)the well(s): OPermanent or OTemporary By signing this form,I hereby certil)'that the well(s)Was(,were)Constructed in ru'eardance
'with I5A NCAC 02C.0100 nr I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or No copy of this record has been provided to the well owner.
If this is a repair.fill out known well construction information and explain the nature of the
repair under#21 remarks'section or on the hack e fthis 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: 1 construction details. You may also attach additional pages if necessary.
For multiple in fertior a'pion-water supply wells ONLY with the same construc(ion,you can
submit one form." SUBMITTAL INSTUCTIONS ,
9.Total well depth below land surface: 585 • (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(41200'and 20000') construction to the following: .
10.Static water level below top of casing: 80 - (ft.) . Division of Water Resources,Information Processing Unit,
If i rater 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
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ROTARY -construction to the following: •,
(i.c.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
20 RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) - Method of test:
PILLS Also submit one copy of this form within 3Q days of completion of
13b.Disinfection type: Amount 35 . well construction to the county health department of the county where
constructed. ,
Forst GW-1 '• North Carolina Department of Enviipnment and Natural Resources—Division of Water Resources Revised August 2013