GW1--04555_Well Construction - GW1_20230713

WELL CONSTRUCTION RECORD For lntemal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers ` `�` Nt. V� '�`N`EM 1 h
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number S UI'P fGGAStM oaorrtnu ii a iott 1a rott it?np1)i able) m > :
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 IL 37 ft. 6.25 #21 Pvc
Company Name W 1 CASING tl)Y` 111Ctkah rmat: psed-ttitil► �a lAileM.;
2023-00196 FROa1 To DIAMETER THICKNESS MATERIAI.
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): ;* SCRBoN ` io i i E
Water Supply Well: FROM TO DIAMETER SLOT SIZE , THICKNESS MATERIAL
ft. ft. in.
DAgricultural ❑MunicipalPublic
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) FROM TO MATERIAL F.MPLACF.MENT METHOD&.AMOUNT
❑ln;gallon 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation nI9NAS/6110L+'I+raKiItiftWat$4 '"g. '' :„.:.NO
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control , ,
4(11. )0Ill; t ' 1G:(attacti rtddititl i il(ei'fsil'.rtecessa _ �/ ,04
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft, 37 ft- OVER BURDEN
5-15-2023 37 ft. 125 ft. GRANITE
4.Date Well(s)Completed: Well ID# ft ft.
5a.Well Location: ft. ft. 7.7 i`—"'3,--- ""_
Charles Taylor �`r�.: - ;L r r
ft, ft. s� t"`
Facility/Owner Name Facility ID#(if applicable) ft. ft. r
197 Wiggins Road Candler, NC 28715 ft. ft.
JUL ` 1L123
Physical Address,City,and Zip r lnj n e in r r n r ' '
Buncombe 8687246580000 x�t��l�mt'A�l�s4 ,w�. „.,.� �nl��t,�,.tt�,,; �. �.����,-,
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 Wt 5-30-2023
Signature of Certifi a Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this firm,1 hereby certify that the well(s) was(were)constructed in accordance
with 15A 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 known well construction information and explain the nature of the
repair under 1121 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
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 1 25 (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 44100') 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
11.Borehole diameter: 6'25 (in.) 24b.For Infection 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:
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-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013