GW1--03535_Well Construction - GW1_20240612

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers 14.WATEA ZONES
FROM TO DES('RIP TION
Well Contractor Name ft. fr.
4471-A
ft. ft.
NC Well Contractor Certification Number 15.Ot TER CASING(for tnuld-eased wells)OR LINER(If ap ksbte)
CLYDE SAWYERS&SON WELL&PUMP INC FROM To IEIANIE TER THICKNESS MuTE:RIAI.
+1 ft. 92 ft. 6.25 in. #21 PVC
Company Name
2020-003 p 7 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: v FROM TO nl:AMr:[ER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State.V,riance.etc.) ft. ft. in.
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17.SCREEN
FRoM I DI\METER p1.0.1 SIZE TIIIC KN INS MATF.RISI.
Agricultural °Municipal/Public ft. ft. in, I
Geothermal(Heating/Cooling Supply) F3 Residential Water Supply(single) ft. tt. in. ,
industrial/Commercial °Residential Water Supply(shared) 18.GROUT
Irrigation F Ron 1 i o I NI A I'I'RI tI. I I.MPI.A CF\II-S I Nit 111011 S a\101'NI—
Non-Water Supply Well: o ft. 20 ft. Bentonite Pumped
Monitoring °Recovery ft. H. Cap Top with Bentomite chips
injection Well: -
ft. ft
Aquifer Recharge ®Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery °Salinity Barrier FRortI To MATERIAL _EMPLACESIENT METHOD
Aquifer Test °Stormwater Drainage ft. ft.
°Experimental Technology (]Subsidence Control ft. ft.
°Geothermal(Closed Loop) 0 Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness.soitirock type.grain size,etc.)
DGeothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) 0 it 92 f[. OVER BURDEN
4.Date Well(s)Completed:3-29-2024 Weil iD# 92 fL 165 ft- GRANITE
ft. ft. — Lam''s F. ,
5a.Well Location:
VINCENT CARANGELO ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. JUN 1 2 2024
DEAR ANGEL WAY FAIRVIEW, NC 28730 ft. ft. If £,I.P.�r.eiMle41 1lte11
Physical Address,City,and Zip I. ft. Mt'Itt"4
BUNCOMBE 9675431442 21.REMARKS ,ts
County Parcel ldentitication No.(PIN) WFLI WAS SFI F CFRTIFIFD
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W 4-5-2024
6.Is(are)the well(s)O% Permanent or ®Temporary Sig e of C.er ed ontractor Date
By signing th brit,I hereby certifi'that the well(s)was(were)constructed in accordance7.Is this a repair to an existing well: (]Yes or %(]No with 1SA;VCAC 02C.01/N)or ISA NC'AC'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:
R.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: 165 (ft-) 24a. for All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if'different(example-30,200'and 2( /0(1') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,information Processing Unit,
If wilier level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.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) 30 Method of test: RIG' 24c.For Water Sootily& lulection Wells: In addition to sending the form to
PILLS the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 20 completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016