GW1-2023-02756_Well Construction - GW1_20230417

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers �'�r..���.,, � ;���� �: N
FROM TO DESCRIPTION
Well Contractor Name
4471-A
NC Well Contractor Certification Number F5:4U TEtt4Cr1SiNG foi maht METE c tls O THICKNESS
1lcaA R
FROM TO DIAMETER THiCKNF.SS MATF.RiAi.
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 51 ft- 6.25 in. #21 PVC
Company Name Iti,iNIV£R CA$►iYG`.OR,TCIBING eo}het>iial"cfused too ':
2022-00391 FROM 'rO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. in
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Mtmicipal/Public
❑Geothermal(Heating/Cooling Supply) OResideatial Water Supply(single)
ft. ft. in•
❑IndustriaVCommercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOM
❑irri ation 0 et• 20 ft- Bentonite Pumped
Non-Water Supply Well:
cc. rt. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation 519 SAND/GRAVEL:°PAC,1 b,i'i$11661 1}
FRO51 TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
ZO�bR1GT:INC'1;"C1G.{attach'idditiatiil`sheots:if,'neeessn �*� a�� �i
❑Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTION color,hardness,soi0rockty a grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 51 ft. OVER BURDEN
2-20-2023 51 ft• 605 ft• GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location: ft. ft.
Aibl Invest LLC ft. ft. APR 1 7
2023
Facility/Owner Name Facility ID#(if applicable) ft. ft.
641 Elk Mtn Scenic Hwy Asheville, NC ft. ft. tr;•- =�:,::�,.l;;d
flu _
Physical Address,City,and Zip 21 RE V1ARK5 '` ,� a
Buncombe 975123013700000
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 2-22-2023
Signature of Cettifi ell Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary
By signing this form,1 herehr certify that the well(s)was(lucre)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENO copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair wader#21 remarks section or on the back oJ'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: 1 construction details. You may also attach additional pages ifnecessary.
For multiple ityec•tion or non-water supply wells ONLY with the saute construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface• 605 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iJ'tlif rein(esantple-3 tit 00'anr12(tul00� construction to the following:
10.Static water level below top of casing: 180 (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 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) 7 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
PILLS
13b.Disinfection type: Amount: 35 well construction to the county health department of the county where
constructed.
Fomi GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013