GW1--01173_Well Construction - GW1_20240219

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1 Prfnt Firm U
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers IarwATElmoivts mi & w - .. .a =:.
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
it. ft.
NC Well Contractor Certification Number >iKbtiTER GAS1P1 (fklifitltt caseii pv ilO lailIVER(irapplleabl'e)tla :' ,',1
CLYDE SAWYERS&SON WELL&PUMP INC FROM TO DIAMETER i THICKNESS MATERAAl.
+1 103 6 25 l in• #21 PVC
Company Name
WEL2022-00380 FROM TO [11tING coklicimatctos`cd Foo" 5 `W
t.
t(i 1NNER:GAS11V •(SR T (g p�,".�.�v r°: `� .�.,+;i,
2.Well Construction Permit#: DIAMETER . THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft. I in.
3.Well Use(check well use): ft, ft. in.
Water Supply Well:b FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/PublicCt. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)industrial/Commercial
ft. ft. in.
Residential Water Supply(shared) lg;Gl OuT ;' M� M >?z c$: n c,,t; :.
lirrigation FROM TO MATERIALEMPLACE;M EMPLACEMENT METHOD&AMOUN'1'
Non-Water Supply'Well: 0 it 20 ft. Bentonite Pumped
Monitoring
Injection Well: Recovery IL ft. I Cap Top with Bentomite chips
ft. ft.
Aquifer Recharge 0Groundwater Remediation
OSANAMIONEVOXCK(if applia lli1W4 ` MONV � a.4..a5 x iX01
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL, EMPLACEMENT METHOD
Aquifer Test 0Stonnwater Drainage ft ft. l'
p Experimenta I Technology in Subsidence Control ft. ft. I,
i
(Geothermal(Closed Loop) ®Tracer f2tlAR1TL1NG3:0iG{at2a'ch"additiunariheetsifuecessary) 'Im5r mt
FROM TO DESCRIPTION(color,hardness,soil/rock type,gram size,etc.)
Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) 1
0 ft 103 ft• OVER BURDEN
4.Date Well(s)Completed: 12-1-2023 Well 1D# 103 ft 305 ft.
p GRANITE
5a.Well Location: ft. ft.
GEORGENA HIXSON ft. ft. _
Facility/Owner Name Facility iD#(if applicable) ft, ft. f.� " " t I ('.-"C
175 ROSE HILL ROAD ASHEVILLE, NC ft. ft. as77"'�"''
Physical Address,City,and Zip ft. ft. I, " Lb j 9 LGL4
BUNCOMBE 966379296 l'2tAtEmAll somo .=; . ;tea - :6*x ' f; `
County Parcel identification No.(PiN) r,ItiIt C
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W
12-14-2023
6.Is(are)the well(s) Permanent or Temporary Signa a of er ed oral-actor Date
X
By signing th.Arm,1 hereby certiJi'that the we//(s),vas(were)constructed in accordance
7.Is this a repair to an existing well: EtYes or %®I No with 15,4 NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
if this is a repair.Jill out known well construction infonnation and explain die 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 firm.
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: 305 (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@,200'and 2 ti l00') construction to the following:
10.Static water level below top of casing: 50 (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.)
r
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,IRaleigh,NC 27699-1636
13a.Yield(gpm) 4 Method of test: RIG 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit oitelcopy of this form within 30 days of
13b.Disinfection type: PILLS Amount: 30 completion of well construction to thl county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016