GW1--05590_Well Construction - GW1_20240916

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers ,�t4F�s,;ATUii ONESW Nt M" : �44a':.
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
ft. ft.
NC Well Contractor Certification Number 15 UU'EEROASN tfarrotiln4nsctl vells)0i I1NER0if'up ticnlite}was- . Pc?`:
CLYDE SAWYERS & SON WELL & PUMP INC FROM TO IMAMr:rsR 'THICKNESS I MATERIAI.
+1 ft• 135 ft• 6.25 ; in. #21 PVC
Company Name 1 RVASN UR�TU t co QINO tbermnCcta cd raiiii tray anW
2.Well Construction Permit#:WEL2023-00221 61(ix7i 1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. ;`in.
3.6 Well Use(check well use): ft. ft. in.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
atCr SllpplV Well: MATERIAL
lVSGRE1:h[ ��e Mi ,, OB Tera4 41
Agricultural 0Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
industrial/Commercial Residential Water Supply(shared) t1$,;ORomfy , — , m sy , :mow-x,k
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&ASIOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite Pumped
Monitoring 0Recovery ft. ft. Cap Top with Bentomite chips
Injection Well: •
ft. ft.
Aquifer Recharge oGroundwater Remediation litq.O,AL41i/G[ti3VEVPACKC(atagpitcat te)' ., ~x' ,ZAT', ," m<
Aquifer Storage and Recovery E3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test j Stonnwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
(Geothermal(Closed Loop) OTracer Zb.$DO.ILILANt 1 C1G{i cii additio)ia[sheets:if irecessa } ' V =, F.`•A`°
�'�,� FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
v e 9eothermal(Heating/Cooling Return) nOther(explain under#2I Remarks) 0 ft• 135 ft. OVER BURDEN
4,Date Well(s)Completed:9-10-2024 Well ID# 135 ft. 265 ft. GRANITE •'^
ft. ft. 11 ,L ice.�.A 4.. . i�i..i
5a.Well Location:
DYLAN HENDERSON ft. ft. SEP 1 6 2024
Facility/Owner Name Facility tD#(if applicable) ft. ft.
RED BUD LANE LOT 2 LEICESTER, NC 28748 ft. ft. Ir5 : iv.en f rcd:;474;P Ue
DiftrCf2ft. ft. �"
Physical Address,City,and Zip
BUNCOMBE 96193755670000 �2tiiA� 0 �z ss� �:lz. V`M
County Parcel Identification No.(PiN) ,V FLI WAS SFI F (:FRTI FI FD
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W 09/12/2024
6.ls(are)the well(s) Permanent or OTemporary Signa e of er ed ont actor Date
By signing th. orni,I hereby certifj'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or EliNo with 15A NCAC 02C.0/00 or ISA NCAC(12C•.(1200 Well Construction Standards and that a
Ifthis is a repair.fill out known well construction infonnation and explain the nature of the copy of this record has been provided to the well owner.
repair under#2I 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 G W-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: t SUBMITTAL INSTRUCTIONS .
9.Total well depth below land surface: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@/00') construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resoti.rces,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
6.25 •
11.Borehole diameter: (in.) 24b. For Iniection 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:
(Le.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 2 769 9-1 6 3 6
13a.Yield(gpm) 30 Method of test: RIG 24c.For Water Supply&Injection I 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: 25 completion of well construction to tie 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