GW1--04488_Well Construction - GW1_20230713

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WELL CONSTRUCTION RECORD (GW-I) For Internal Use Only:
1.Well Contractor Information:
Kolby Sawyers 14:TWATERZONRs . .. .:. ,, . .
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
ft. ft.
NC Well Contractor Certification Number
15:;OUTER CASING`(for m6ltt cased')tells)'ORLINER:Ofiipp-licnbler:...-
CLYDE SAWYERS& SON WELL& PUMP INC FROM TO DIAMETER THICKNESS II MATERIAL
+1 ft. 78 ft. 6.25 in• #21 1 PVC
Company Name
384829—� 'I6:`INNER,CASiNG,OR'TUBING(gedthernialclosed loop),. ', _,,.
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State.Variance.etc.) ft. ft. , ill.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17;SCREEN :. . .l 4 _ '. .., „ . .a, ... .
FROM TO DIAMETER SI OT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) E3 Residential Water Supply(single)
ft. ft. in. •
IndustriaUCommercial OResidential Water Supply(shared) 18 GROUT , ;
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft• Bentonite Pumped
Monitoring Recovery ft. ft. Cap Top with Bentomite chips
injection Well:
ft. ft.
Aquifer Recharge DGroundwatcr Rcmcdiation
',19.SAND1GRAVEUPACK-'(if applicable) -, ":
Aquifer Storage and Recovery ID Salinity Ban'ier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test D Stomtwater Drainage ft. ft.
Experimental Technology [3Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer :',20.DRILLING LOG(attach'additionai sheets if odcessar}) ,
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM ft.
DE: P I'I e
0 ft• 78 ft• OVER
SCRI BURDENON(color,hardness.soil/rock type,grain size,etc.)
4.Date Well(s)Completed:06/21/25023 Well ID# 78 it 205 ft* GRANITE
ft. ft.
5a.Well Location:
Colby Clark ft. ft. Ni'-'"
Facility/Owner Name Facility ID#(if applicable) ft. ft. �o ��.•�,• f lsr 1„�
Flint Morgan Road, Mars Hill 28754 ft. ft. JUL v 2023
Physical Address,City,and Zip ft. ft.
Madison 9746-93-3500 2l.RENIARRSi . t1113ti7i=afi-.rr.'' . c' -,;i7 fare ;,
County Parcel Identification No.(PIN) this well was self certified
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W 06/22/2023
6.Is(are)the w•ell(s)OPermanent or Temporary Sigma cofCe cd onnactor Date
By signing th them,I hereby certify that the well(s)was(were)constructed in accordance
7.is this a repair to an existing well: DYes or IZINo with iSA NCAC 02C.0100 or iSA FICA('02C.0200 Well Construction Standards and that a
If this is a repair,Jill out known well construction inJbrmation and erplain the nature oldie copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this forum.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 205 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Ga1200'and 20100) construction to the following: '
10.Static water level below top of casing:20 (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 Infection Wells: In addition to sending the form to the address in 24a
ROTARY above, also submit one 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&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: PILLS Amount: 20 completion of well construction to the county health department of the county
where constructed.
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources; Revised 2-22-2016