GW1--03521_Well Construction - GW1_20230519

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
zV,14RATEitZnB: r
Kolby Mitchell Sawyers FRONT TO DESCRIPTION
Well Contractor Name
4471-A
NC Well Contractor Certification Number €�15.,.OUTER=(ASING for'tuulti=ca +felts.t=NE1t ifI`IIca61e
FRONT TO DIAMETER THICKNF,SS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 98 ft• 6.25 '" #21 PVC
Company Name iNNEW0A9tK0 tlR,'I�JC
2022-0041 FROM '1'O D1AMKTF.R THICKNESS MATERIAL
2.Well Construction Permit#: 2 ft ft. to
List all applicable uvIl permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17:
Water Supply Well: FRONT TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/P.ublic in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in,
❑lndustrial/Commercial ❑Residential Water Supply(shared)
FRONT TO MATERIAL EMPLACEMENT MF.T IOD&AMOUNT
❑in; ation 0 rc. 20 ft. Bentonite Pumped
Non-Water Supply Well:
rc. rt. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
f 9Si3Ni1/GRi'tEIPAGK't a' Ule � c.. ; =
❑ LAAquifer Storage and Recovery []Salinity Barrier FROM TO
ft. ft. MATERIAL ENIP CEME.VT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
"20. 'llu17;�fi 501 1G-41tiac nddiHoKi 1 streets ifriecessarv`
❑Geothermal(Closed Loop) ❑Tracer FRONT TO DESCRIPTION color,hardness,soiVrock type. rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fr. 98 ft. OVER BURDEN
3-28-2023 98 ft 505 ft GRANITE
4.Date Wells)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft. _',z7
Leah &Andrew Zetterholm -
ft. fr.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. MAY
1, Q 2023
31 Hunting Lodge Drive Black Mountain, NC 28711
Physical Address,City,and Zip FI REMX K$ 3," O,,�0A M' �
Buncombe 0619712134 Well Was Self Certified
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N `,1t 4-10-2023
Signature of CcrtifiyWell Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary �,
By signing•this firm,orm,I hereby•certi that the wells()was were constructed in accordance
with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Nell 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 knonw well construction information and exphiin the nature of the
repair under#21 remants section or on the back oJ'1his farm. 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-water supply wells ONLY with the same construction,you can
submit one farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 50 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths ifdfNrent(example-3 d) 00'and 2(a,100') construction to the following:
10.Static water level below top of casing: 160 (ft.) Division of Water Resources,Information Processing Unit,
If mvier fare/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) 2 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form iwithin 30 days of completion of
PILLS
13b.Disinfection type: Amount: 35 well construction to the county health department of the county where
constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013