GW1--03556_Well Construction - GW1_20240612

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers 14.WATER ZONES -
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
4471-A
ft. ft.
NC Well Contractor Certification Number 15,OUTER CASING(for Could-cased wells)OR LINER(if ap icable)
CLYDE SAWYERS&SON WELL&PUMP INC I.I10Ni 1.0 DI AMElFR lHI('KSISS MAT FRIAI.
+1 ft. 34 ft. 6.25 in. #21 PVC
Company Name 2024-00160 16.INNER CASING'OR TURiNC(geothermal closed-loop)
2.Well Construction Permit#: (mist TO uI\>u_rr:R nuc 4 n n�rss NI
all applicable wrflconstruction permits tie.Ll/C,County,State,Variance,etc.) ft• It. in.
3.Well Use(check well use): ft. ft. la.
Water Supply Well: t'.SCREEN
pPPROA1 TO D11ME'I'FR ii 01 SIZE TIII(KSFSS NI NTERI NI.
Agricultural ®Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ft. ft. in,
Industrial/Commercial
Irrigation
Non-Water Supply Well:
Residential Water Supply(shared) 18.GROUT
FROM I O \1\I'FRU I F\I PI.\('P MF'S I Mf fl{qD&N\IUt Vl
0 D. 20 ft. Bentorste Pumped
Monitoring
Injection Well:
Recovery ft. ft. Cap Top with Bent xnite chips
ft. ft.
Aquifer Recharge ®Groundwater Remediation
19,SAND/GRAVEL:PACK(if applicably)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL. _ EMPLACEMENT METHOD
Aquifer Test OSlormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
�I(icothermal(Closed Loop) ()Tracer 20.DRILLING LOG(attach additional sheets it-necessary)
FROM 'f0 DE SCRIP (color,hardness,soil/rork type.gran dra.r{c.)
OGeothermal(Heating/Cooling Return) ()Other(explain under#21 Remarks) 0 ft. 34 ft. OVER BURDEN
4.Date Well(s)Completed:5-10-2024 Well iD# 34 ft. 1005 fL GRANITE
ft. ft. M it •I s,��/ ....
5a.Well Location: �,``e i... E
SAUL BEAS PALOMERA ft. ft.
Facility/Owner Name Facility 10(1(if applicable)
ft. ft. JUIV I 2 Za24
92 HOLLY RIDGE CANDLER, NC 28715 ft. ft.
it t*sl @ i P.rr_y`-',1 _thg
Physical Address,City,and Zip ft. ft. fYIrCd;Cv
BUNCOMBE 8696050419 21.REMARKS
County Parcel Identification No.(PiN) ---
5b.Latitude and longitude in degrees/minutesiseconds or decimal degrees:
(if well field,one laVlong is sufficient) 22.Certification:
N W 5/31/2024
6.Is(are)the wel(s)0Permanent or ®Temporary Signa e of Le ed ntractor Date
By signing th min,1 hereby cerfifj'that the wellfsl wws(were)constructed in accordance
7.Is this a repair to an existing well: 0 Yes or xONo with 15A NCAC 02C.0100 or 1SA NCAC 02(.'.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 hack 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: 1005 (ft.) 24a. For All Wens: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2(l ot)') construction to the following:
10.Static water level below top of casing:400 (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 Infection 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) 1/2 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: 35 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016