GW1--07517_Well Construction - GW1_20231120

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers 14.WATER ZONES
Well Contractor Name FROM To IIk:SCKIPIION
R. ft.
4471-A
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR I INER(if applicable) 1
CLYDE SAWYERS&SON WELL& PUMP INC FROM Tu utANIF.IFR IIll Is\F,', NI AI ERIAI.
*1 it. 34 ft. 6.25 in' 421 l PVC
Company Name
WE L2023-0 0264 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM To DI,(NII'TER 1T11C K NESS MATERAAI.
List all applicable well construction permits(i.e.U/C',County.State.Variance.etc.) ft. It. in.
3.Well Use(check well use): it. ft. in.
Water Sulppl Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) MI Residential Water Supply(single) ft. ft. in.
Industrial/Commercial []Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO !MATERIAL FAIPI.A(F:M ES I'METHOD&AMOFNI
Non-Water Supply Well: a R• 20 R• Bentonite Pumped
Monitoring Recovery ft. ft. Cap Top with Bentomite chips
Injection Well: ft. ft.
Aquifer Recharge °Groundwater Remediation
IS.SAND/GRAVEL PACK(if applicableL
Aquifer Storage and Recovery °Salinity Barrier FROM TO NI N 01(111. I EM1'I.s(T:MENT NIE-MUD
Aquifer Test °Stormwater Drainage t't. It.
Experimental Technology D Subsidence Control 1't. It.
Geothermal(Closed Loop) D Tracer 20.DRILLING LOG(attack additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) []Other(explain under#2I Remarks)
D R. 34 ft• OVER BURDEN
4.Date Well(s)Completed: 10/0212023 Well ID# 34 ft' 185 R' GRANITE
5a.Well Location: ft. ft.
Kenneth Whiffed Jr. ft. R ,
Facility/Owner Name Facility ID#(if applicable) R. ft.
160 Porter Ln, Asheville 28803 ft. ft. NOV 2 9 202' -
Physical Address,City,and lip ft. ft.
Buncombe 96577517150000 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
N " 10/09/2023
6.Is(are)the Nsell(s)E3Permanent or °Temporary Signs a of Ce ed onlraclor Date
By signing th orm,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or EiNo with I5A NCAC'02C.010(3 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#21 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.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: 185 (ft.) 24a: For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if Afferent(example-3@200'and 2@a 100) construction to the following:
10.Static water level below topof casing:25
g (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
IL Borehole diameter: 6.25 (in.) 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.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) 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: 15 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016