GW1--07515_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
FROM lO 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 ft• 78 ft• 6.25 in. #21 Pvc
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
WEL2023-00224 FR°AI DIAMETER T HICK NESS AIAIIRIAI.
2.Well Construction Permit#: it. ft. in.
List all applicable Nell permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREE N
Water Supply Well: FROM TO DIAMETER _SLOT SIZE THICKNESS MATERI AI.
ft. ft. in.
❑Agricultural ❑Municipal/Public
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single)
ft. ft. in.
❑lndustrial/Conimercial ❑Residential Water Supply(shared) Ik GROUT
FROM TO MATFRIAL FAIN_ACEMENTMETHOD&AMOUNT
❑irrigation 0 ft' 20 ft. Bentonite Pumped
Non-Water Supply Well:
rt. rt. 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
❑Aquifer Test ❑Stormwater Drainage
—
ft. ft.
❑Experimental Technology 0 Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIP1 ION(color,hardness,soil/rock type.grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 78 ft. OVER BURDEN
10-10-2023 78 ft• 225 ft• GRANITE
4.Date Well(s)Completed: Well ID#
R. ft.
5a.Well Location: ft. ft.
Leicester Ridge Holdings ft. ft. (�J
NO V i gj 7l.lC1
Facility/Owner Name Facility ID#(if applicable) - ft. ft.
15 Alaskan Dr., Leicester ft. it. . —
Physical Address,City,and Zip
21,REMARKS _. ...
Buncombe 9701778530 _ This well was self certified
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 w (IA 10 12 2022
Signature of citified Well Conlratarte/ 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 ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or allo ropy of this record has been provided to the well onner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back if this jarm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.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 some construction.you 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-34200'and 24100) construction to the following:
10.Static water level below top of casing: 30 (g•) Division of Water Resources,Information Processing Unit,
If muter level is above caring.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.c.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 teat: 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 of Environment and Natural li,esources—Division of Water Resources Revised August 2013