GW1--07512_Well Construction - GW1_20231120

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: L
Kolby Mitchel Sawyers �t`WATER ZONES
Well Contractor Name FROM 10 DESCRIPTION
ft. ft.
4471-A —
_ ft. ft.
NC Well Contractor Certification Number IS.OCTER CASING(for multi-cased wells)OR LINER(if ap licable)
CLYDE SAWYERS & SON WELL & PUMP INC FROM TO DI.AMRI'ER THICKNESS MVITRIAI.
+1 ft. 68 ft. 6.25 in" #21 PVC
Company Name
tni �2�23-��� 16.INNER CASING OR TUBING(geothermal closed-loop}
2.Well Construction Permit#: 75 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fL ft. in.
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17.SCREEN
FROM f0 DI-tMFIFR St(Tr STZE TITI(KNFSS NIA TT
Agricultural ®Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) E3 Residential Water Supply(single)industrial/Commercial
Non-Water Supply Well:
H. ft. in.
®Residential Water Supply(shared) i8.GROUT
irrigation FRO\I (0 \I-\I'F.RIAI F\IPl ACFMF;\I\IFIHOD&SMOIJN'I
0 ft 20 tr• Benlonite Pumped
Monitoring DRecovery fL ft. Cap Top with Bentomite chips
Injection Well:
ft. fr.
Aquifer Recharge ®Groundwater Remediation
1R,SAND/GRAVEL PACK(if applieabl
Aquifer Storage and Recovery DSalinity Barrier FROM To \Inn ERLu, 4:Nn'L.0 Ia uiN 1 METHOD
Aquifer Test DStonnwater Drainage ft. ft.
BExperimental Technology 0 Subsidence Control ft. fr.
Geothermal(Closed Loop) OTracer Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) necessary)
20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,h soil/rock type,grain sin,etc.)
0 fL 68 ft OVERBURDEN
4.Date Well(s)Completed:9-29-2023 Well iD# 68 tL 185 ft' GRANITE
fL ft.
5a.Well Location:
Christina Fisher fL ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. 11/ )
658 Alexander Road Leicester, NC 28748 fL ft. 9 11.11,
Physical Address,City,and Zip ft. ft.
Buncombe 97123318870000 21.REMARK ';" '
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' 10-20-2023
6.ls(are)the well(s)D% Permanent or ®Temporary Sig a of C er ed on tractor Date
Bp signing th ornl,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: D Yes or EiNo with ISA NCAC 01C,1)11X)or 1SA NCAC(I2C.tl200 Well Construction Standards and that a
If this is a repair.fill out known well construction information and explain the nature of the copy of this record has been provided to the sell owner.
repair under#1l 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 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
9.Total well depth below land surface: 185 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple veils list all depths if different(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 wafer 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
13a.Yield(gpm) I 0 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
136.Disinfection type: PILLS Amount: 20 completion of well construction to the county health department of the county
where constructed.
Form C.W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016