GW1-2023-02770_Well Construction - GW1_20230417

WELL CONSTRUCTION RECORD For IntemaI use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers '14:.tS 1TEItZONES
FROM TO DESCRIPTION
Well Contractor Name ft' ft.
4471-A R. rt.
NC Well Contractor Certification Number 15:-OU'CER'CASING flic'tnuift c6ed.ivelts Ak'Ll1VRR�i;6 lleat)le' a� .fix... raw
FROM TO DIAMETER THICKNESS MATERIAL.
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. 48 ft- 16.25 #21 PVC
Company Name y,16.1NNER`CASiNGURTCS'IN etifh sed ermut'clo -Ino '�� A " .f .r
FROaI '1'0 DIAMF.'rKR 'THICKNESS MATERIAL
2.Well Construction Permit#: 2022-00390 ft. ft. in.
List all applicable vivil permils(i.e.Couno�,State,Variance,Injection,e(c.)
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
in.
❑Agricultural ❑Municipal/Public
in.
❑Geothermal(Heating/Cooling Supply) ©Residential Water Supply(single)
tt. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL RMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft' 20 ft. Bentonite Pumped
Non-Water Supply Well:
rt. rt. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑GrouudwaterRemediation �19.�SANFIGRAl� �EACK�efaUea61e�FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Storm-water Drainage
ft. ft.
❑Experimental Technology El Subsidence Control
2UcDRIbLTNG'7 CfG attacti'addltiantttsheets:ifficecessary a:,x .<, .
❑Geothermal(Closed Loop) ❑Tracer FRonr TO DESCRIPTION color,hardness,soil/rock tv a grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 8 ft. OVER BURDEN
2-21-2023 48 ft- 505 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft.
AIBL INVEST LLC
Facility/Owner Name Facility ID#(ifapplicable) R. ft. APR 1 t I
631 ELK MTN SCENIC HWY ASHEVILLE , NC 28804 ft. ft.
Physical Address,City,and Zip
Ys Y, P zZt:RENTARKSs':r . ( tF? 'r. ,.< ',.
Buncombe 975113724400000 -
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one fat/long is sufficient)
N w 2-24-2023
Signature ofCcitiflyWell Contractor f Dale
6.is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,I here'v certify that the well(s)was(were)constructed in accordance
with 15A NCAC 03C.0100 or 15A NCAC 02C.0200 Nell 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 repair,fill out Anown well construction information and explain the nature of the
repair under#21 remarks section or on the back t f'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
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple hyec•tion or not-water supply wells ONLY xdth the same constructiort,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 505 —(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths:J'Ji/jerent(example-3 d 00'unt12(u 100� construction to the following:
10.Static water level below top of casing: 120 (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 Cen i ter,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: Amount: 35 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013