GW1--06020_Well Construction - GW1_20230920

":22221fl
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: `
Kolby Mitchel Sawyers i4 WATET Drres : r Z
RrellContraclorName FROM TO DESCRIPTION
ft. ft.
4471-A
ft. ft.
NC Well Contractor Certification Number
15Aill'[ERGA$It1tGr(fortiiu[ti dascaEfi's);tlteLARRx(ffWP iC&Gtlr} ', MPM
CLYDE SAWYERS&SON WELL& PUMP INC FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. 285 ft" 625 Ito #21 PVC
Company Name A'"
2023-00177 1G llvly£R:Ci1SfIG'CIRTUBIM1G;(g #hormaWcToscd-(oo"`, e, ,,
2.Well Construction Permit#: FROM TO DIAMETER TIHCKNESS 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: .17A lte.„0�. DIAMETER -. f ,,,, ', ',
FR
SLOT SIZE THICKNESS MATERIAL
*Agricultural C]Municipal/Public ft. ft. in.
*Geothermal(Heating/Cooling Supply) E3Residential Water Supply(single) ft. ft. in.
'industrial/Commercial 0 Residential Water Supply(shared) i8.,G cityr kAtth 1.1-mtwar „� , ,�. o
......I irrigation FROM TO MATERI.AI. EMPLACEMENT METHOD&AhIOUN'I'
Non-Water Supply Well: o 11. 20 ft. Bentonite Pumped
$1Monitoring fRecovely ft. ft. Cap Top with Bentomite chips
Injection Well:
ft ft.
iAquifer Recharge ®Groundwater Remediation
?i4,,Se1191?IGRA',VEOPAGKI(f,•aihutUli'�}��*': + MOS ,
*Aquifer Storage and Recovery Salinity Barrier PROM TO MATERIAL EMPLACEMENT METHOD
IIIIAquifer Test 13Stonnwater Drainage ft. ft.
'Experimental Technology 0Subsidence Control ft. ft.
jN!Geothermal(Closed Loop) OTracer PU.711t11`,I.11V01401(Rita¢ltaddrlibnalshiiis,if'nesessnri5' • —
FROM TO DESCRIPTION(color.hardness,soil/rock type.grain size,etc.)
!Geothermal(Heating/Cooling Return) 13 Other(explain under#21 Remarks)
0 it 63 ft• OVER BURDEN
4.Date Well(s)Completed:2023-00177 Well ID# 63 ft' 285 ft" GRANITE
5a.Well Location: ft ft.
Alex Fedun ft. ft. -,y_ ,
"t j-_.,,
Facility/Owner Name Facility ID#(if applicable) ft. ft. Z .�.J lam.fi �J �t
22 Governors View Road Ashville, NC 28805 ft. ft. SEP n 2023
Physical Address,City,and Zip ft. ft.
Buncombe 965854936300000 1 RE -MARKS' = MA. 4ifx.0kkif am 4, W—' '.
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:
N N' 8-14-2023
6.1s(are)the well(s) X Permanent or ]. Temporary Signa e of er ed ontractor Date
By signing th out,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or ElNo with 15.4 NCAC 02C.0/00 or 1SA NCAC ON.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 VI remarks section or on the back of this form. i
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:1SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: 285 (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@200'and 2 a 100') construction to the following:
10.Static water level below top of casing:20 (ft.) Division of Water Resources,information Processing Unit,
1/'water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:'6.25 n.
(i ) 24b. For injection 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
(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) 50 Method of test: RIG 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit orie,copy of this form within 30 days of
13b.Disinfection type: PILLS Amount: 30 completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016