GW1--01092_Well Construction - GW1_20240216

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1
1.Well Contractor Information:
Kolby Mitchel Sawyers ttewATERizoNt. ...- 4.: ' ,. w' z4
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
ft. ft.
NC Well Contractor Certification Number 415 0(3,[1JWOWNt1Yl•>(fpi motfd=cas wet)"x).{)tt=`LlN1;R(irurt bete).. OvateM
CLYDE SAWYERS&SON WELL&PUMP INC FROM TO DIAMETER ' THICKNESS MATERIAL
+1 ft. 54 ft• 6.25 : io. 21 PVC
Company Namc
td
WP22-088 1NYER ANNOACTOIDNOAS a�r�til'elneii4iti _ ', ,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(.e.UIC,County,State,Variance,etc.) ft. ft. ! in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 175CRE>
FROM _ TO DIAMETER . SLOT SIZE , THICKNESS MATERIAL
ill Agricultural ®Municipal/Public ft. ft. in.'
•
11Geothermal(Heating/Cooling Supply) Ea Residential Water Supply(single) ft. ft. in.
ilndustrial/Commercial OResidential Water Supply(shared)
i irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft. Bentonite, Pumped
*i Monitoring pRecovery ft. ft. Cap Top with Bentomite chips
Injection Well:
ft. tt
!Aquifer Recharge ®Groundwater Remediation , A- /GAAYE1IPA 3Kitif nppliaabilN) M � IS '
*Aquifer Storage and Recovery ®Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
al Aquifer Test 0 Stonnwater Drainage ft ft. ,
Experimental Technology [3 Subsidence Control ft. ft.
MI (Closed Loop) OTracer 2O: I MLAPIO flGtartach:addtti'analshe s Ciiecessai) '
FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
a Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
0 ft. 54 ft. OVER BURDEN
4.Date Well(s)Completed: 11-8-2023 Well ID# 54 ft 545 ft GRANITE
5a.Well Location: ft. ft. _,� f-' 77 •...
Regina Dougher ft. ft. V LL,
Facility/Owner Name Facility ID#(if applicable) ft. ft. FEb 1 e 2f`7A
419 Boulder Ridge Road Brevard, NC 28712 ft. ft. 1� 4
ft ft. tiht,ttttacF'�,1 s ;:5¢."y,F;4 -'
Physical Address,City,and Zip (jj���j;�7�
Transylvania 8552-20-3632-000 2tzQ] EMATtKS ��' � �
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 N' 11-21-2023
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6.Is(are)the well(s) Permanent or OTemporary Signs e of Cer ed onlractor Date
x
By signing th. oral,I hereby certifj'that the well(s)was )tere)constructed in accordance
7.Is this a repair to an existing well: ®Yes or DINo with 15A NCAC 02C.0101)or 15A NCAC 02C.0200 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 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'
9.Total well depth below land surface: 545 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi different(example-3(a1,200'and 2@100') construction to the following: ,
10.Static water level below top of casing:?00 (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 infection 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) 2 Method of test: RIG 24c.For Water Supply&Iniecltion Wells: In addition to sending the form to
the address(es) above, also subunit 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.
Form OW-i North Carolina Department of Environmental Quality-Division of Water ResourcIes Revised 2-22-2016