GW1--03546_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.WATER ZONES
FROM TO DES(RIPTION
Well Contractor Name
ft. ft.
4471-A
ft. rt.
NC Well Contractor Certification Number 15,OUTER CASING(for mold-cased wells)OR LINER(if aft kabIe)
CLYDE SAWYERS&SON WELL & PUMP INC FROM TO DI SNIFFER THICKNESS MATERIAL.
+1 ft. 88 ft. 6.25 In. #21 PVC
Company Name
2023-00423 16.INNER CASING OR TUBING(geothermal closed-loop)
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: 17.SCREEN
FROM TO DI%Mil IFR SLAT SIYF, TRH KSISS MATF.RI11.
Agricultural ®Municipal/Public rt. It. in.
Geothermal(Heating/Cooling Supply) Cl Residential Water Supply(single) ft. ft. in.
industrial/Commercial ()Residential Water Supply(shared) �g GROUT
Irrigation I.RUM TO NI I'F-.RI\I. I.MP!ACESIIST MI TROD&4MO1.5't
Non-Water Supply Well: 0 ft 20 ft. Bentonite• Pumped
Monitoring ()Recovery ft. ft. Cap Top with Bentomite chips
injection Well:
ft. Cr.
Aquifer Recharge ()Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0Salinity Barrier FROM TO SI4TF:RLM L:MPI..NCE>IEN I METHOD
Aquifer Test ()Stonnwater Drainage ft. ft.
Experimental Technology ()Subsidence Control ft. ft.
(isothermal(Closed Loop) ()Tracer 211.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color.hardness,soil/rock tIpe.grain Mu,etc.)
Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks)
0 ft as ft. OVER BURDEN
4.Date Well(s) 4-16-2024 Completed: Well iD# 68 ft. 185 ft• GRANITE �� .r
�, P • c
_5a.Well Location: ft ft. I i`LI L.. V L—t
GAIL AUSTIN ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft. JUN 1 2 ZOZ4
70 FOX BRANCH ROAD FAIRVIEW, NC 28730 ft. ft. w m siCil F. S`',!URX
MaltPhysical Address,City,and Zip ft. ft.
BUNCOMBE 96950375440000 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field one lat/long is sufficient/ 22.Certification:
N A' 4-22-2024
6.Is(are)the well(s)D% Permanent or ()Temporary Signa e offer ed ontractor Date
By signing th orm,I hereby serial),that the well(sl am(were)constructed in accordance
7.Is this a repair to an existing well: 0 Yes or d No with 15,4 iVCAC OW.0/00 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 cola'of this record has been provided to the well owner.
repair under#21 remarks section or on the hack of this form.
23.Site diagram or additional well details:
R.For Ceoprobe/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: 85 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple'veils list all depths if different(example-3@200'and 2(/Q0') construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water 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 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) 15 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
I 3b.Disinfection type: Amount: 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