GW1--06714_Well Construction - GW1_20241108

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES--;-� ,^5 , .,•. ',,` , .. ... ,, i.
Derrick Heath Sawyers FROM TO DESCRIPTION I
Well Contractor Name ft. ft.
2436-A ft. it.
NC Well Contractor Certification Number ,15:OUTER CASING(formutti-cased wells)OR DINER(if a() !feeble), ?" �x , ,.,
FROM TO DIAMETER • THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 38 ft. 6.25 in• #21 1 PVC
Company Name P16.°INNER CASING OR TUBING(geotlfeeriialclosed loop) .":' * ,1
2022-00509 FROM TO DIAMETER THICKNESS MATERIAL
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.SCREEN "`:t
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. to
ft. ft. in.(Heating/Cooling Supply) ElResidential Water Supply(single)
Dindustrial/Commercial ❑Residential Water Supply(shared) l$.GROUT s�. " '_ _: - !`''"
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 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 ❑GroundwaterRemediation tt19:SAND/GRAVEL PACK(ifapplieable)_ - a .'-;
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery El Salinity Barrier ft. ft
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
.-20,DRILLING LOG(attach additional;ssbeets iffieetssafy} ,"_' ,
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,Brain size,etc.) ,..
OGeothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft• 38 ft- OVER BURDEN
38 ft- 245 ft• R—ZRA.,,,,iiN:1T:4;0,2,,,it;,2
10-24-2024 i.
4.Date Well(s)Completed: Well ID# ft. ft. ✓ ;�5a.Well Location: ft. ft. 1y/' u.:..-R&S INVESTMENTS OF WNC,LLC ft. ft. IVO" 6O
Facility/Owner Name Facility ID#(if applicable)
ft. ft. Ifr`G1.'11rui.`-":P^r,`.,21,-.:*a',1 L.a
INDIAN PAINT BRUSH LOT #40 ft. ft VAT' +1 r -..K
Physical Address,City,and Zip
Buncombe 972126255400000 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 latilong is sufficient)
N N ANtrzoik 10-23-2024
Signature Well Contract° Date
6.Is(are)the well(s): 2IPermanent or ❑Temporary By signing f fy () (were)this ram,I herebytern that the wells was were constructed in accordance
with ISA 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 ONo copy of this record has been provided to the well owner.
If this is a repair,fill out knower well construction information and explain the nature of the
repair under#21 remarks section or on the back 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
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 I
submit one form. ,1 SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 245 (ft) 24a. For All Wells: Subunit this form within 30 days of completion of well
For multiple wells list all depths ifd jerent(example-3@200'and 2@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
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11.Borehole diameter: 6.25 (in.) 24b.For Infection Wells ONLY: iln'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.) i
Division of Water Resources,iUnderground Injection Control Program,
I FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
100 RIG 24c.For Water Supply&Injection'Wells:
13a.Yield(gpm) 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.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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