GW1-2022-07617_Well Construction - GW1_20220817

WELL CONSTRUCTION RECORD For Interval Use ONLY:
This form can be used for single or multiple wells
1,Well Contractor Information:
Kolby Mitchell Sawyers FR FROOM TO TER7O�1 TO DESCRIPTION
Well Contractor Name
ft. ft.
4471-A ft. ft. i
NC Well Contractor Certification Number 155;OUTTWCAS1NG foriiiulf3 cased vetls:ORiLINER.ifa` ticable'
FROM TO DIAMFTF.R TRiCKNFSS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. 115 ft- 16.25 I '" #21 1 PVC
Company Name 16'<IEVtVER CA$ING UR:TURING.`eoth, it ctesCtt lao _. :..
2022-00031 FROM .1'0 DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: in.
List all applicable well permits(i.e.Counnv,State,Variance,Injection,etc.)
ft. ft, in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal Meatin /CooNn Supply) OResidential Water Supply(sin(single)
❑lndustriaUCommercial ❑Residential Water Supply(shared) �.
FROM TO MATERIAL EMPLACEMENT METHOD&.AMOUNT
❑lni ation 0 20 ft- Bentonite Pumped
Non-Water Supply Well:
1't. ft.
❑Monitoring ❑Recovery
injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19sSAND/GRA3tiPAC :ifa `cable.....:a J> �:�......f.i:
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Storntwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
2diD1ttG1,I394'`; C1GE�ttaeli at7t31tiaiii sTteEts:iLanecessa.: :... ..:...: ;__ ;
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiurmit type. rain size,etc.)
❑Geothermal Heating/Coohn Return ❑Other(explain under#21 Remarks) 0 ft• 115 fr OVER BURDEN
6-01-2022 115 ft- 205 h• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: rt. ft.
Brandon Keith
a i Y d....' ®.e
Facility/Owner Name Facility ID#(if applicable)
Dix Creek #1 ft. ft. AUG 1 7 2022
Physical Address,City,and Zip - = �.
21._;EMARI�S a..... r.
11
Buncombe 9609857932 CANOSOG
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W Cso 07/6/2022
Signature of Certifi ell Coutractor I Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this fcn•m.1 hereh.v certify that the uvll(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 nr 1 SA NCAC 02C.0200 14 ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy of this record has been provided to the well owner.
If this is a repair.fill out Anuisn well construction iufurmation and explain the nature of the
repair under#21 remarks section or on the.back Qf this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-water supply wells ONLY with the same constructiun,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 205 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welts list all dePthv if dqf rent(example-30200'and 2(a,,100') construction to the following:
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
7f water level is above casing.use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection Wells ONLY:! In addition to sending the form to the address in
ROTARY 24a above, also submit a copy of�this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.c.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)
7 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 35 well construction to the county health department of the county where
constructed. I
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013