GW1-2023-02763_Well Construction - GW1_20230417

WELL CONSTRUCTION RECORD For Internal Use ONLY.
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers
FROM14,PWATER4
TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft. i
NC Well Contractor Certification Number AMR)0 T F R,,CA S I 04or'muli3 cased i ela'owCINJ9 0V 61I a616
FROM TO 1 THICKNESS 3rATF.RiAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 44 It. 16.25 iO 1 #21 PVC
Company Name X161tVNt,RCASIl.t%OMTUIa1N epilieernialclo"RI440
2022-00518 FROM 1'O DIAmF.,r.R 'THICKNESS MATERIAL
2.Well Construction Permit#: rt. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft ft. in
3.Well Use(check well use):Water Supply Well: FROM To DIAMETER SLOT SIZE I THICKNESS I 3fATERiAL
❑Agricultural ❑Municipal/Public ft. ft. in,
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) .19-X9 V1'KW
FROM TO MATERIAL FMPLACFAWNT METHOD&AMOUNT
❑i,ri ation 0 ft' 20 ft- Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery, Cap Top with Bentonite Chips
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation 9o'MNBYGRV91YP.ARS;'ilsax 1"bI ' Z .A �
❑Aquifer Storage and Recovery ❑Salinity Barrier
FRO31 ft.
ft.. . MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
El Experimental Technology ❑Subsidence Control x
k2b�DRIi1I:iN��1:0011ilaclt�addrhorial'sheefs 1f=n`ecessa ': ^
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soi0rockty a grain size,etc.)
❑Geothermal (Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 44 ft. OVER BURDEN
4-10-2023 44 ft- 165 ft. GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
Lori Miller '-
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. ' PR 1 s J
75 Anderson Cove Road Barnardsville, NIC 28709
ft. ft
Physical Address,City,and Zip f
Buncombe 9774563248
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 W 4-11-2023
Signature of Certifi ell Contractor Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By sibnting this firm,1 herehv certify that the well(s)was(were)constructed in accordance
ivith ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy ofthis record has been provided to the well owner:
If this is a repair,fill out known well construction in l rmation and explain the nature of the
repair under#21 remark section or on the back ofthis.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 some construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 165 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ij'di/ferent(example-3@2 00'and 2(a100) construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
Ifmuter level is above casing.use"+•' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection 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
13a.Yield(gpm) 12 Method of test- RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amouut• 20 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