GW1--04761_Well Construction - GW1_20240812

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers 14.WATERZONES
IRON To DESCRIPTION
Well Contractor Name
4471-A ft. ft.
IL ft.
NC Well Contractor Certification Number 15,OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
CLYDE SAWYERS&SON WELL & PUMP INC FROM '1'O DIAMKTER 'THICKNESS MAT FACIAL
+1 ft. 101 ft. 6.25 in• #21 PVC
Company Namc �„. — —
202q-����� ¢,INy LR(ASINC OR TURING(geothermal closed-loop)
2.Well Construction Permit# J FROM ro I11A 11ETLK THICKNESS MATERIAL
List all applicable ne/I construction permits ti.e.LUC,Coun(v,State. Variance etc.) ft. ft. hi.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 1?.SCREEN. {
FROM TO DIAMETER SI.OT SIZE THICKNESS 'SIATFR1:Al.
DAgricultural °Municipal/Public ft. ft. in.
°Geothermal(Heating/Cooling Supply) }3 Residential Water Supply(single) ft ft. in.
°Industrial/Commercial °Residential Water Supply(shared i 18,GROUT _
1)lrrigation FROM i O MA 'FRI S1 F Al'I.ACFMF:N I METHOD&AntOEN'r
Non-Water Supply Well: o ft 20 ft. Bentonite Pumped
°Monitoring °Recovery fL ft. 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 `Ears to sis min NI, Estrt..lct.\iENr METHOD
°Aquifer Test 0Stonuwater Drainage ft. ft.
Experimental Technology °Subsidence Control ft. ft.
(isothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets,ifnecessary) ,
FROM TO DESCRIPTION(color,hardness soil/rock type.gruiu size,etc.)
°Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) 0 ft. 101 ft• OVER BURDEN
4.Date Well(s)Completed:6-4-2024 Well iD# 101 ft• 505 ft• GRANITE
ft. ft. t�'-_ .
Sa.Well Location: F• * ' ):;.
Olga Castaneda fL ft.
Facility/Owner Name Facility ID#(if applicable) ft ft. AUG I 2 2024
6 Giovannas Way Leicester, NC 28748 ft. ft.
Irtv1:4:--, A-r,. `:-,t',let —
Physical Address,City,and Zip ft. ft.
BUNCOMBE 9702721866 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/tong is sufficient) 22.Certification:
N W 6-18-2024
6.Is(are)the well(s)J% Permanent or ®Temporary Signa a of ter ed ontmctor Date
BE signing th unit,1 hereby cent ji'that the weB(sy was(were)constructed in acca'dance
7.Is this a repair to an existing well: ®yes or X°No with/5,4;VCAC 02C.1)101)or 15A NCAC 02C'.020(1 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 if this farm.
23.Site diagram or additional well details:
S.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: 505 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-J(000'and 20'100') construction to the following:
10.Static water level below topof 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) 5 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: 35 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