GW1-2023-01945_Well Construction - GW1_20230227

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells 1
1.Well Contractor Information:
Kolby Mitchell Sawyers
FROM TO DESCRIPTION
Well Contractor Name
4471-A ft. ft.
NC Well Contractor Certification Number t5'011(1{;C+ffiLt�G toriiiiilti caeeil;�vetls':01t,'t l�l�tt-ifsficalite`.
FROM TO DIAMETER TAICKNF,SS MATF.RiAT.
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft 135 it 6.25 I i" #21 PVC
Company Name
16=IIVI�IER'i i1$INGOR;T,UBli1 ; COtliNiflBlfitOSEiIIQi1-`' '' '' ,.'•`
2021-00619 EROaI DIAME'rEft THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. ! in.
List all applicable well pennits(i.e.County,State,Yariance,7n/ection,etc.) ft ft, in.
3.Well Use check well use): , :. <-_E..:__.Water Supply Well: FRONT TO DIAMETER SLOT SIZE THICKNESS MATERLAL
ft. ft.❑Agricultural ❑Municipal/Public in.
in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single)
ft. ft.
❑indusmaUCommercial ❑Resldenual Water Supply(shared) E
FROM TO MATERIAL EMPLACEMENT METHOD&.AMOUNT
❑hTi ation 0 ft. 20 fr. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
[]Aquifer Recharge ❑GroundwaterRemediation
FROM TO 1VIATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control ,-
3bzi11Tt1G1t19�'il:tttl':
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,suiurock typa grain size,etc.)
❑Geothermal (Heating/Cooling Return 00ther(explain under#21 Remarks) 0 ft- 135 ft, OVER BURDEN
01-12-2023 135 it 245 it GRANITE
4.Date Well(s)Completed: Well ID#
i
5a.Well Location:
Airo Way LLC '
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. FEB ?,
Slate Dr., Lot 34, Candler ft. ft. lnfoTa.aliz-n Proc.w%inj Urn
Physical Address,City,and Zip S:r:=::
ys ty P �;7'R AR""K
Buncombe 8698697761I This well was self certify
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one fat/long is sufficient)
N `,tr 01/13/2023
signature of Ceitifi ell Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this farm,I herehv certify thal the well(s)was(ivere)constructed in accordance
with 1 SA NCAC:02C.0100 or 1 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 onmer.
If this is a rrpair.fill out known well construction itfurmation and explain the nature of the
repair under 921 remarks section or on the back ofthis farm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also;attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same constructivn,you can
submit one form. 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 da ptlis ifdiJfer•ew(example-3(aj200'and 2(w100) construction to the following:
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
Ifwaler level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection Wells ONLY-1 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&Injection Wells:
,
Also submit one copy of this formlwithin 30 days of completion of
PILLS well construction to the county filalth department of the county where
13b.Disinfection type: Amount: 35 i
constructed.
Form GW-1 North Carolina Department of Euvironnient'and Natural Resources-Division of Water Resources Revised August 2013