GW1--07508_Well Construction - GW1_20231120

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: '
Derrick Heath Sawyers 14•WATERZONES
FRAM TO DESCRIPTION
Well Contractor Name ft. ft.
2436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 It• 78 f1' 6.25 in. #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
WEL2023-00224 PROM '10 DIAME li „lt llCKNESS ,IA IEEE!Al
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,lyection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN _
Water Supply Well: FROM TO DI VHF TER _SLOT SIZE 'THICKNESS \I ATERI AL
ft. ft. in.
DAgricultural ❑Municipal/Public _
['Geothermal(Heating/Cooling Supply) hJResidential Water Supply(single)
ft. ft. in.
� B/ B PPY) PPY( g
❑lndustriallCommercial ❑Residential Water Supply(shared) 1R.GROUT
FRO 11I TO MATERIAL FAIN"CEMENT METHOD A-AMOUNT
❑lrigation 0 ft. 20 ft' Bentonite Pumped
Non-Water Supply Well:
ft. ft. Cap Top with Bentonite Chips
[Monitoring ❑Recovery
Injection Well: It. ft.
❑Aquifer Recharge ❑Groundwater Remediation. 19.SAND/GRAVEL PACK(if applicable)
). FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ['Salinity Barrier ,,' ft. R.
[Aquifer Test ❑Stormwater Drainage •t.
ft. ft.
❑Experimental Technology ❑Subsidence Control r
.20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) ❑Tracer • :4.• FROM I TO DESCRIPTION(color,haniness.soil/rock type.grain size,etc•I
OGeothermal(Heating/Cooling Return) ['Other(explain under#21 Reinatks) 0 ft. 8 ft. OVER BURDEN
10-10-2023 78 ft. 225 h• GRANITE
4.Date Well(s)Completed: Well iD# .
ft. ft.
59.Well Location: ' . ft. R.
Leicester Ridge Holdings ft. ft.
Facility/Owner Name Facility ID#(if applicable)
15 Alaskan Dr., Leicester • ft. ft. _ Nf 11l 'ill
Physical Address,City,and Zip 21.REMARKS T
Buncombe 9701778530 This well was self certified :_
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W S 10-12-2022
Signature of citified Well Contrite Date
6.Is(are)the well(s): RIPermanent or :Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ErlNo 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 nature of the
repair wider till remarks section or on the back of thin form. 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 •ou can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 225 (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(aj200'and 24 10(Y) construction to the following:
10.Static water level below top of casing: 30 (ft-) Division of Water Resources.Information Processing Unit,
If muter 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 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) 50 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: 20 • well construction to the county health department of the county where
• constructed.
Form G W-1 North Carolina Department-f fivatiartieul and Natural Resources—Division of Water Resources Revised August 2013
a•