GW1--03540_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.WA1 ER ZONES 7
Welt Contractor Name
FROM To uFscRlPnuv
4471-A rt. ft.
rt. ft.
NC Well Contractor Certification Number
IS.OUTER CASING(for multi-eased wells)OR LINER(if a licable)
CLYDE SAWYERS& SON WELL & PUMP INC FRa1M lit DIt\1I II It I11I('KNENS NA FERIAE
Cl fL 106 ft. g 2; in. a21 PVC
Company Name
2023-00458 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM lt) DIAMETER r ItICk'cftt M [FRI O.
List all applicable well construction permits(i.e.U/C,County.State,Variance.etc.) ft. ft. in.
3.Well Use(check well use): II. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THI(k\FSS _ MATERIAL
Agricultural EDMunicipal/Public ft. R. in.
Geothermal(Heating/Cooling Supply) ra Residential Water Supply(single) ft. ft. in.
Industrial/Commercial [J Residential Water Supply(shared) IS.GROUT
Irrigation _FROM TO NATERIAL_ F.NIPLACF:MENT METHOD&AN101i N)
Non-Water Supply Well: o ft. 20 It. Bentonite Pumped
Monitori ng D Recovery R. ft. Cap Top with Bentomite chips
Injection Well: R. ft.
Aquifer Recharge OGroundwater Remediation
f-�-� 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery tJ Salinity Barrier FROM 10 NLATERtAi. EVI'I.A(ENIEN T NIL HOD
Aquifer Test [J Stormwater Drainage ft. ft.
Experimental Technology [3 Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20,DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks)
0 ft. 106 R• OVER BURDEN
g fL s=-. 6'f c
03/05/2024
4.Date Well(s)Completed: Well ID# 106 245 GRANITE i • `„t L e t, ia. j
5a.Well Location:
R. ft. JUN 1 2 2024
KENNETH CAMBY R. ft.
Facility/Owner Name Facility ID#(if applicable) fL R I1AG't Sit tl f'e.t..a114tw4 Unit
58 HILL SIDE DRIVE FAIRVIE, NC ft- ft. tMcrt1t 4
Physical Address,City,and Zip ft. ft.
BUNCOMBE 06061213020000 MI,REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ---
(if well field,one lat/long is sufficient) 22.Certification:
N " 03/05/2024
6.Is(are)the well(s)0Permanent or OTempnrary Sign, ol'Cc ed ontracwr � Date
By signing th orm.I hereby cert,,Jy that the aell(s)war(here)constructed in accordance
7.Is this a repair to an existing well: 0 Yes or ®No with ISA PICA'02C.0I00 or I5A 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 lt21 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: ' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 245 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@.200'and 2®100) construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
limiter 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) 10 Method of test: RIG 24c.For Water Supply&Injection 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: 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