GW1-2023-00664_Well Construction - GW1_20230105

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
t
Kolby Mitchell Sawyers FROM TO DESCRTMO:,
Well Contractor Name ft. ft. I
4471-A ft. ft.
NC Well Contractor Certification Number W06T0V.CAWG`.for*I Mtl Ri liiiiiii
FROM O MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 44 ft- 6.25 ' #21 1 PVC
Company Name 16r'INNER CASING,OR<TUB1N kofhern7aEctpsed-log __.:-_;. �;
2021-��4�1 FROM TO DIAMFTER THICKNESS MATb:RL41.
2,Well Construction Permit#: ft. ft. in.
List all applicable um//permits(i.e.County,State,Parlance,Injection,etc.) ft ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIANTETER SLOTSiZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft, in
❑Geothermal(Heating/Cooling Coolin Supply) EIResidential Water Supply(single) ft. ft. in.
� � g PPP) PPP( g
I!S t':ROUT
❑IndastriaUCommercial ❑Residential Water Supply(shared)
FRONT TO MATF.RiAL EMPLACEMENT NfF.TROiI&AMOUNT
❑T7,; ation 0 ft. 20 ft• Bentonite Pumped
Non-Water Supply Well:
ft. tt.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediatio» 19,-SrS1YDlGRANEL TACK d°a'licrrble .-..-
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM [t. TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
2drlT)21t[1NG's t3k,:atfa_ch_ addltoniilsheaEsif` essa. --; ,
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION enlDr,hardness,soivrmk type rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) 0 44 f' OVER BURDEN
11-30-2022 44 f` 245 f` GRANITE
4.Date Wells)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft. ;•-.;� .. aN.A' ''
Lucky House Project LLC ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) I
124 Saddle Ridge Dr Lot 5
ft ft
�, � 1 r
Physical Address,City,and Zip
Buncombe 97128950230000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certitication-
(if well field,one lat/long is sufficient)
N WVaN 01/03/2023
Signature of Ceitifi ell Coutractor Date
6.is(are)the well(s): ❑Permanent or ❑Temporary f f
By minb si �this form,1 herehv ecru that the well(s)was here constructed in accordance
with 15A NCAC•02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No copy of this record has been provided to the well owner.
If this is a repain fill out knonw well construction information and explain the nature of the
repair under#21 remarks,section or on the back ofthis 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 if necessary.
For multiple injection or non-hater supply wells ONLY with the same construction,you can
.submit one jam. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 245 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if difjerem(cramp/e-3(ez!200'and 2(w100� construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
If uuler level is above casing.use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection 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.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) 10 Method of test- RIG 24c.For Water Supply&t Injectiori 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 i e i Ith department of the county where
constructed.
Fom GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013