GW1--07474_Well Construction - GW1_20231120

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers 1iMMTSR ZOt ' ; ; ., ',
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
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4471-A
ft. ft.
NC Well Contractor Certification Number 31SAAPl'EtWAM tG,;{fdr taunt cas4Yt;tvells)tlli+l%t1iEEi{ifap tfcalile)
CLYDE SAWYERS&SON WELL&PUMP INC FROM TO DIAMETER THICKNESS MATERIAL
+1 ft 140 ft• 6.25 tn' #21 PVC
Company Name -, x,
1s INIVERVAsir`s C7r3 T116INdikailf rmalsctoscaliVf s '''
2.Well Construction Permit#:WP23-096 FROM TO DIAMETER THICKNESS , MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft• ft. in,
3.Well Use(check well use): ft ft. in.
Water Supply Well: ts?scREENs " ;k; m ,, , i,, 9
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
al'Agricultural DMunicipal/Public ft. ft. in:
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INiGeothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in
*iindustrial/Commercial DResidential Water Supply PP Y(shared)
181GROU'C* . ,,,
iirrigation FROM TO MMA'I'ERItAI. EhIP1.ACEMEN'r METHOD&AMOUNT
Non-Water Supply Well: o ft• 20 ft. Bentonite Pumped
W I Monitoring DRecovery ft. ft. Cap Top with Bentomite chips
Injection Well: -- - '
ft. tt
'Aquifer Recharge ()Groundwater Remediation
1?SANbIGRAVEOPAMelitaflppllCihIe) ' ° :.
',Aquifer Storage and Recovery ®Salinity Barrier _FROSt TO MATERIAL EMPLACEMENT METHOD
RiAquifer Test (3Stonnwater Drainage ft. ft.
l tExperimental Technology ®Subsidence Control ft. ft.
�!Geothermal(Closed Loop) ®Tracer I20111.ILLt�0E(1GWttac i gditttiona>"sheetsltiiecess`h�-
FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
al Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) - - ;
0 ft. 140 ft• OVER BURDEN
4.Date Well(s)Completed: 11-10-2023 Well ID# 140 ft. 485 ft• GRANITE
5a.Well Location: ft ft. ,
Brent Sanders • v..--- '
Facility/Owner Name Facility ID#(if applicable) ft. ft. n)Ol/ 9 2023
308 Capps Road Pisgah Forest, NC 28768' ft. ft. NOV VV
Physical Address,City,and Zip ft. ft. I'
Transylvania 8597-95-3725-000 VIIMatilitaiktW4 ' � ;
County Parcel identification No.(PiN) this well was self certified
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iatflong is sufficient) 22.Certification:
N W 11-12-2023
6.Is(are)the well(s) X Permanent or Temporary Signa e of er ed onh rdor Date
By signingdh oral,1 hereby cerrifi'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or EtNo with 154 NCAC 02C.0100 or 15A NCAC 02C'.0200 Well Construction Standards and that a
If this is a repair.fill out known well construction infonnation and explain the nature of the copy of this record has been provided to die well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same 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,
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9.Total well depth below land surface: 485 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 70 (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: 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
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13a.Yield(gpm) 2 Method of test: RIG 24c.For Water Supply&Injection Wells: 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: 35_ completion of well construction to the county health department of the county
where constructed. I
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Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016
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