GW1--04556_Well Construction - GW1_20230713

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: •
Kolby Mitchell Sawyers ..4. rA I=zOI s w w7a.' . - mc
moz
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft. 1
NC Well Contractor Certification Number
lefa'O i"'t itttASt +t �t'a roof=ca ed 'ftiP i t i SEEC(,e '>ilieaiite)t l ' ` ,
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 87 ft. 6.25 in. #21 Pvc
Company Name t6„Il01Eft CAMNGI+f1R�T'.UB7N('1;kepthCrmaE-clu5ed+ibtt't'ea. , '%'ss.. '.�'
2021-00349 FROM TO DIAMEtER THICKNESS MATERIAL2.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): 747eSCREENC. ,. .W.;£,,,...k. . 4- f. lT`,•-%
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑MunicipaUPublic .
❑Geothermal(Heating/Cooling Supply) EResidential Water Supply ft. tt m
(H ('j g PPY) PPY
❑IndustriaUCotnmercial ❑Residential Water Supply(shared) 'ICGRO "' ' `` �� " ` ` W ` sf A''
rrY
FROM it.' MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft. 20 ft• Bentonite Pumped
Non-Water Supply Well:
ft. ft. Cap Top with Bentonite Chips
❑Monitoring DRecovery
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation 719,4.AIIICIII YEL""PACK'(ii.a(tptit gle) , A ?." ` ,,,44
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
DExperimental Technology ❑Subsidence Control ..
alailtllsiilNC:tOOv{aftkiii4nfdihai' s eti�ifitecessarY)r-` `,sW� >-P"4
DGeothermal(Closed Loop) DTracer FROM TO DESCRIPTION(color,hardness.soilfrock type.grain size,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft. 87 ft. OVER BURDEN
5-25-2023 87 ft. 265 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft.
•'...
BIG HILLS CONSTRUCTION LLC ft, ft. s ‘ .'tw.'lh i V ,R.,1,t
Facility/Owner Name Facility ID#(if applicable) ft. ft. AI II 1 g
STONE RIDGE @ HAYES MTN LOT 8 CANDLER, NC 28715 no
ft. ft.
Physical Address,City,and Zip 20lRll'J'd'Rt WAVV 'Mc ltl a!'+; t nr 'EMW# `' ,
BUNCOMBE 8698628530000 1.).W.Q 14..<i
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 5-30-2023
Signature ofCertifi a Contractor Date
6.is(are)the well(s): ❑✓Permanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or J5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or IEINo 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 mature of the
repair under#21 remarks section or on the back of this them. 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 if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 tih 00'and 2@100) construction to the following:
IQ.Static water level below top of casing:40 (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 Injection Wells ONLY: In addition to sending the font 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) 1 0 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 30 well construction to the county health department of the county where
I constructed. ,
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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