GW1--06032_Well Construction - GW1_20230920

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
1.Well Contractor Information: i ,
I Kolb Mitchel Sawyers 14 �Af�1 �7s :� r
mtw ., ', emzuww'a
FROM _ TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A fa ft. I
NC Well Contractor Certification Number z 15 t3 Ingle ASIt`Offtir tntili caseii a'ells)'`f)R"GINER'(if'iip lieatij"e) l 1
CLYDE SAWYERS&SON WELL & PUMP INC FROST To DIAMETER 'THICKNESS MATERIAL
+1 fL 42 ft' 6.25 In' #21 PVC
Company Name FROM
2022-00371 1d�1Niv>~R e�sSirrtr tIR TiiBINC��crm aiteai'cllosot}itop� ���v . ,
2.Well Construction Permit#: TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. , in.
I .
3.Well Use(check well use): ft. ft. in.
`„1.7c SCREE,NY 44M M; # „ 'IN4,1 AcO` - z:, ,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
*Agricultural 0Municipal/Public ft. ft. in.
*Geothermal(Heating/Cooling Supply) DI Residential Water Supply(single) ft, ft. in.
j*industrial/Commercial ®Residential Water Supply(shared) ig:GROUTS: . , 'OBR ` ., i s`c`, ' is raa
I Irrigation FROM 'I'O MATERA.AI. ENIPLACEMEMr METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. Bentonite Pumped
$i Monitoring [3Recovery ft. ft. Cap Top with Bentomite chips
Injection Well:
ft. ft.
j♦1Aquifer Recharge E3 Groundwater Remediation 49;Se1 19118 To�/GRt1VEL PACsK"(ifliiiP11461 2' x`. 1 x `
*Aquifer Storage and Recovery [3 Salinity Barrier MATERIAL EMPLACEMENT METHOD
$l Aquifer Test ®StonnwaterDrainage ft. ft.
*I Experimental Technology fj Subsidence Control ft. ft.
$I Geothermal(Closed Loop) OTracer 10:DRILti11VOTilt:s(ariicli additiiiiii sheets f:iiecessar})
FROM TO 1 DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
IIII Geothermal(Heating/Cooling Return) E3 Other(explain under#21 Remarks)
0 ft. 42 ft• OVER BURDEN
6-30-2023 42 it 245 ft
4.Date Well(s)Completed: Well iD# GRANITE,
ft. ft. I k t-� e _' I A .. .
5a.Well Location: 4' 't k.,, L_r i__
Brandon King ft. ft. [ `�
Facility/Owner Name Facility ID#(if applicable) ft. ft. SE a v `O��
1102 Old NC 20 Hwy Leicester, NC 28748 ft. ft. 1
l,l(urrl ^.n Pr r .,4;: 3 Ur::
Physical Address,City,and Zip fL ft. D1t`'ri'b"3 t7
Buncombe 9712478203 42 WREMARKs gf 7' o.- '404
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W 7-15-2023
6.ls(are)the well(s) X Permanent or OTemporary Signa e of er ed‘aniraaor Date
By signing th bum,I hereby certif'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or }No with 75.4 NCAC 02C,0100 or 75A NCAC 02C'.0200 Well Construction Standards and that a
copy If this is a repair.fill out known well construction information and explain the nature of the co 1. of this record has been provided so the,well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
R.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the sank You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
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 depths if d�erent(example-3@200'and 2(@ 100') construction to the following:
10.Static water level below top of casing:20 (ft.) Division of Water Resources,information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
ROTARY above,also submit one 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(gym) 20 Method of test: RIG 24c.For Water Supply&IniectioniWells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: PILLS Amount: 25 completion of well construction to thle county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016