GW1--01176_Well Construction - GW1_20240219

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: I I
Kolby Mitchel Sawyers Ia v TERID1V S i I 1 F4 61
FROM TO ` DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number AIS'iUU`C>rRGAS1tISIfx(fo'r'uniti en chills};f7RxLINEletifi `ttealrte}r x: ., .
CLYDE SAWYERS&SON WELL&PUMP INC FROM TO DIAMETER ' THICKNESS MATERIAL
7 6.25 lito #21 PVC
Company Name
WE 1"6'�iNtv1£R C;►StNG I3R 7`
L2023-00500 +1 " g OBINCI(ka hormafetoiicd ;op)`lti McAtWe "�"
2.Well Construction Permit#: FROM TO 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. fit. 'rn.
Water Supply Well:
h
FROG( TO DIAMETER SLOT SIZE THICKNESS MATERIAL
.Municipal/Public [[, ft. in
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft in.
I.
industrial/Commercial Residential Water Supply(shared) gGROUI �E ��.fix � On �� s
irrigation FROM TO rtIATItRi.4i." EMPLACRMFNThIETHOD&AMOUNT•
Non-Water Supply Well: 0 fit• 20 fit Bentonite j; Pumped
Monitoring Recovery ft. ft. j Cap Top with Bentomite chips
Injection Well:
ft. ft. 1
Aquifer Recharge 0Groundwater Remediation j
l`iCSANV/GRANEI., AM(ifappliatif};e , ,s,:,;,,V,, OM.ZMN o Mkx, 3c=a.
Aquifer Storage and Recovery ®Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®Stonnwater Drainage ft. ft.
pBExperimentalTechnology ['Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer f(1 bR1Is1 11VG?I()G(attai}`a"ddrh$iifil slteets f:necessary)� ... z ::zNii
FROM TO DESCRIPTION(color•hardness,soil/rock type.gram size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft. 7g ft.
OVER BURDEN
4.Date Well(s)Completed: 1-29-2024 Well ID# 79 fit• 185 ft' GRANITE ,
ft. ft.
5a.Well Location: _
TRI STATE PROP LLC ft. ft. •'tit ,(�e tz 1 a �;r:
Facility/Owner Name Facility ID#(if applicable) ft. ft. a�
2287 SMOKEY PARK CANDLER, NC 28715 ft. ft. l 1 b 1 2024
Physical Address,City,and Zip fL ft I !!.,,,RVrr'rMd4ien,,
BUNCOMBE 86878377090000 ' I` 4�mM INO x � '1 r * '
County Parcel identification No.(PIN) Well was self certified
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one IaUlong is sufficient) 22.Certification:
N NI'
2-8-2024
6.ls(are)the well(s)0Permanent or ['Temporary Signa e of er ed ontrador Date
By signing th arm,I hereby certify that the well(,)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or IDNo with ISA iVCAC 02C.011)0 or iSA 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:imp owner.
repair under#21 remarks section or on the back r f 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 toprovide 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
j
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this foim within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2 tc 100') construction to the following: 1'
10.Static water level below top of casing: 30 (ft.) Division of Water Resourc Is,Information Processing Unit,
.fiwater level is above casing,use"+^ 1617 Mail Service Centier,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
(i.e.auger,rotary,cable,direct push,etc.)
i.
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center;Raleigh,NC 27699-1636
i
13a.Yield(gpm) 20 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: 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 1 Revised 2-22-2016