GW1--03520_Well Construction - GW1_20230519

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
NC Well Contractor Certification Number 15 Ott:tit RrC 1SItY fo 'ttiitld cas¢ditetts OK'LINE[t'iY'a lioa$le ,s'I'
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 158 ft. 6.25 #21 PVC
Company Name lfi 11yfVER CASFIV R T1i131hG euthermatclosed Io'o`�7 0"'�1�t
2023-00023 FROM 'ro DIAME F..R THICKNESS MATERIAL
2.Well Construction Permit#: ft tt, in.
List all applicable ouch permits(i.e.County,State,1'ariance,bnjection,etc.) ft fL in.
3.Well Use(check well use): 1' SC,I?ECl!T iw"_
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal eatin Coolin Supply) EIResidential Water Supply(single) ft. ft. in.
� � g PPY) pPY( g
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 et. 20 ft. Bentonite Pumped
Non-Water Supply Well:
rt. rt. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: t't. 11L
❑Aquifer Recharge ❑Groundwater Remediation i9 SAND/CRi1StELEt K iCa licatieai � _ Y.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To nwTER1AL EDIPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
[I Experimental Technology ❑Subsidence Control
%i20:;DRII;L1Nt <lG(aitacti"addtRunat€sttee4�sif-atecc'sshiv�'.- W '
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION eoior,hardness,soillrmk type. rain size.etc.)
❑Geothermal Heatin Coolin Return) ❑Other(explain under#21 Remarks) 0 ft' S8 ft• OVER BURDEN
4-26-2023 58 tt• 145 ft• GRANITE
4.Date Wells)Completed: Well ID#
ft. ft.
5a.Well Location:
John Eldreth
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Long Ridge Road Candler, NC 28715 ft. ft.
Physical Address,City,and Zip 21 RENifiRisS_Buncombe 8695531907 c� M
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
N W Q2 5-5-2023
Signature ofCcrtiflirwell Contractor I Date
6.is(are)the well(s): RPermanent or ❑Temporary By signing this form,I herehv certify that the well(s)was(were)consiructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 M'ell 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 repair,fill out knoxn well construction information and explain the nature of the
repair under#21 remarka 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
8.Number of wells constructed: construction details. You may also attach additional pages ifnecessary.
For multiple h jection or non-water supply ivells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 145 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ij'dijferew(example-3 ar 00'and 2(a100) construction to the following:
10.Static water level below top of casing: 1 (ft.) Division of Water Resources,Information Processing Unit,
If uuter 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)
20 Method of test: RIG 24c.For Water Supply&Injection, Wells:
Also submit one copy of this form within 30 days of completion of
PILLS
13b.Disinfection type: Amount: 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