GW1--01094_Well Construction - GW1_20240216

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers I4 t ASt•.EItIzeirt I.
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number .k -_ •. . .a _.
15,�+Jt3tERxG�I'tY+:�;(fol<tttulti cased„ e0s�`s(ilt�(,11�E[t�(If' llcafile}� '
CLYDE SAWYERS&SON WELL&PUMP INC FROST TO DIAME'1•ER, THICKNESS MATERIAL
+1 rt. 140 fc• 6.25 I ln• #21 PVC
Company Name f
ellkiNeftV`'ASINCDR;TI IN Willeraia5;'etbscd=1' p
2.Well Construction Permit#:WP23-096 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): ft. ft. in.
Water Supply Well: t�f 5ti1 EN
FROM _ TO DIAMETER SLOT SIZE THICKNESS MATERIAL
*Agricultural 0 Municipal/Publ ic ft. ft. in, .
*'Geothermal(Heating/Cooling Supply) ta Residential Water Supply(single) ft. ft. in.
*industrial/Commercial ®Residential Water Supply(shared) 't&p/Gtto = :» :mot ? '
a!irrigation FROM TO MATF..RIAI. EMPLACEMENT MRTHOD&AMOUNT
Non-Water Supply Well: o ft• 20 ft• Bentonite Pumped
Al Monitoring ORecovery ft. ft. Cap Top with Bentomite chips
Injection Well:
ft. ft. , -
alAquifer Recharge ®Groundwater Remediation '
1:‹Si1ND/41tA ESPAC•10iti»pplicl"lilV.°. b" '11i 4
NI Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
*Aquifer Test 0Stonnwater Drainage ft. ft. i
I)(M Experimental Technology ®Subsidence Control • ft. ft. ;.
*Geothermal(Closed Loop) ®Tracer ICORIT'l"1NOLf1G(airaeTi addilia ialbsh`e" t"sxifai cessat's- <. „
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
a 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. R.
Brent Sanders ft. ft. 1 ,:t`a-.ka V t .
Facility/Owner Name Facility ID#(if applicable) ft. ft. FEB 1 C 224
308 Capps Road Pisgah Forest, NC 28768 ft ft.
Physical Address,City,and Zip ft ft. tru r,`-ggion P5.74 ryr:2,L'n)
I
Transylvania 8597-95-3725-000 sifRREIBARkS . " : , At AAS,-,- -411tsraistos
County Parcel Identification No.(PiN) Well was self certifiAd
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N N' 1 11-20-2023
6.Is(are)the well(s) Permanent or Temporary Signa e of en' ed1M onlractor Dale
x
By signing di bun,1 hereby certifj'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0 Yes or x No with 15,4 NCAC 02C.0100 or 15A NCAC(12C.0200 Well Construction Standards and that a
((this is a repair.fill out known well construction irlfonnation and explain the nature oft/re cop of this record has been provided to the well owner.
repair under 821 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Ceoprobe/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: 485 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dyierent(example-3@,200'and 2 a I00) construction to the following: I
10.Static water level below top of casing:80 (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
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.
Form OW-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016