GW1--06006_Well Construction - GW1_20230920

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ��� � ��� ��
1.Well Contractor Information:
Kolby Mitchel Sawyers
�Pe1lConnactorName
FROM TO DESCRIPTION
ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number 15e((iil:)•itiVASJNO,(hurt ii tigr id lvellitOfti ilVVER 0 lfail`e) 2 a
CLYDE SAWYERS&SON WELL &PUMP INC FROM TO I)IAMEI'ER 'THICKNESS MATERIAI.
+1 ft* 72 ft• 6.25 ! in. #21 PVC
Company Name
2023-00173 AN i R CA'S iStiZO 4ENic ae gorntat efosed t O ' 7 • COM
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL - -
List all applicable well construction permits(i.e.UIC,County,State.Variance,etc.) ft. ft. , in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: i,7tSCREE N '. k`�
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
*Agricultural ®Municipal/Public ft. ft. in.
*!Geothermal(Heating/Cooling Supply) 12.Residential Water Supply(single) ft. ft. in.
*iindustrial/Commercial EiResidential Water Supply(shared) VICGROUU 0 w�� ,' ", - a n 1.
ilrrigation FROM TO MIATERIAI. EMPI.ACRMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite Pumped
*i Monitoring E3 Recovery ft. ft. Cap Top with Bentomite chips
Injection Well: -
ft. ft. ,
*IAquifer Recharge ®Groundwater Remediation
ISANO/GRAVEL t KA tiialieatfl j , 4- 4a
*1Aquifer Storage and Recovery ®Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
'Aquifer Test ElStonnwater Drainage ft. ft.
*i Experimental Technology ®Subsidence Control ft. ft.
MO Geothermal(Closed Loop) ®Tracer ?.r20 11R11.tING3 41GRatfach additionaltheate'lbnecessai} R `,
FROM TO I DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
*Geothermal(Heating/Cooling Return) ®Other(explain under#21 Remarks)
0 ft, 72 ft• OVER BURDEN
4.Date Well(s)Completed:7-11-2023 Well 1D# 72 it 225 ft' GRANITE
5a.Well Location: ft. ft. _ -
CMH Homes Inc ft. ft. rt. at...;'1V CLI
Facility/Owner Name Facility ID#(if applicable) ft. ft. S E P 2 v 2023
Pete Luter Road Candler, NC 28715 ft. ft.
Physical Address,City,and Zip ft. ft. t ,;i^it Pf:'•Csai4✓:i1g l)I:
lntO�
Buncombe 9608513530000 1>IhENIARK.S IN,' ` ' : -INN
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
i
N NV 7-11-2023
6.Is(are)the well(s) Permanent or O�Temporary Sigma a of er ed ..„
untrsctor Date
X
By signing di farm,I hereby cerrij•that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or %3No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair.fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#l1 remarks section or on the back of this form.
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:t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells lb all depths if different(example-3@,200'and 41).1001 construction to the following:
1
10.Static water level below top of casing:40
(ft.) Division of Wafer 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 Injection Wells: In addit Ion 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) 7 Method of test: RIG 24c.For Water Supply&Injection 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: 35 completion of well construction to the county health department of the county
where constructed.
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Form(iW-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016