GW1--01179_Well Construction - GW1_20240219

i
,
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Derrick Heath Sawyers r 14.T\'i l'LI(4ZONGS;i.-rN. aa5, Muc. r ".,r3. a,
FROM TO DESCRIPTION
Well Contractor Name ft.. ft.
2436-A ft. ft.
NC Well Contractor Certification Number t53.0(iGRI(G SING(fari)i¢Iticased'wells)'OIt;LINgteftfiappltcatile)' sv,'=
FROM TO DIAMETER I I THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 11. 94 ft- 6.25 I;it)! #21 PVC
Company Name ..1G 1N1NER"GASfbM1111.€T[tB11\G(>;ea)Iternml-clo'sed taop); E . '':W t z
2023-00202 FROM To DIAMETER' ' THICKNESS MATERIAL2.Well Construction Permit#: ft. ft. 1 in.
List all applicable well permits(i.e.County.State,Variance,injection,etc.) ft. ft. 1 in.
3.Well Use(check well use): t7 SCRE1;#Y ,,. It, t: 1iWO fit* ;,r' 'W,,. AID *i1
Water Supply Well: FROM TO DIAMETER •SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) EResidential Water Supply(single) ft. ft. in.
( EJ g PPY) pPY
❑Industrial/Commercial ❑Residential Water Supply(shared) ''I GROUT mac. IAA < ' o' a A `'.'W, Y 01 `ig,;',,•
FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
Obligation 0 ft. 20 ft- Bentonite ; Pumped
Non-Water Supply Well: -- -
❑Monitoring DRecovery ft. ft. Cap Top with Bentonite Chips
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation .19 SAND/GRAYELPACK`(ifapplicitbie)WV..;z s s ::, A.s1, ,'"
FROM TO MATERIAL' EMPLACEMENT METHOD
DAquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
DAquifer Test ❑Stormwater Drainage .
ft. ft.
DExperimental Technology ❑Subsidence Control _ '
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,1,rdnarv��0:-IkRIGL3N {};G{attach�ddrhana7:"sheets iftc
ardaess soil/rock type.grain sue etc.)
DGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 94 ft. OVER BURDEN
2-5-2024 94 ft- 225 ft. ' ' GRANITE
4,Date Well(s)Completed:. Well 1D# ft. ft.
5a.Well Location: ft. ft. wn 1"J ��-t
William Enete 7 r` �� �i � 1
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. F EB 20Z4
143 Buckner Road Black Mtn, 28711 ft ft
ort'ut i'Crirn Pry^' ^ UnY.
Physical Address,City,and Zip
21..REYIARKS� `.,,:; I~M,= ,cg 00,. "='W=it
Buncombe 062957377400000 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 ladlong is sufficient) i
2-7-2024
Signature of citified Well Contract°if i Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this fermi,1 hereby certify that the well(s)was(were)constructed in accordance
with 1SA NCAC 02C.0100 nr 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair raider 021 remarks section or on the back tf this firm. 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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same 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-3(a�00'and 24;100') construction to the following: ,
10.Static water level below top of casing: 20 (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 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
(i.c.auger,rotary,cable,direct push,etc.) j ,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centieri Raleigh,NC 27699-1636
13a.Yield(gpm) 10 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
PILLS
13b.Disinfection type: Amount: 22 well construction to the county health department of the county where
I
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resolurces Revised August 2013