GW1--03533_Well Construction - GW1_20240612

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers - 14.WATER ZONES -
I.ROp1 '1'O DESCRIPTION _____________.________________
Well Contractor Name ft. ft.
4471-A
ft. ft.
NC Well Contractor Certification Number 15.011ER CASING tfor meld-cased wells)OR LINER(If ap kable)
CLYDE SAWYERS & SON WELL & PUMP INC FROsI TO DAME ILA THICKNESS MA'rERIAI.
+1 it. 63 ft. 6.25 III- #21 PVC
Company Name
WEL2023-00454 16,INNER CASING OR TUBING(ictltherm al cloacd-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits ti.e.UIC,County,State.Variance.etc) 1't. ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well:
Water Agricultural 0A4unicipal/PublIC 17.SCREEN
Fitoat ro oltstl:I R �lor�tze •rHICKsess StnrrRral
ft. ft. in. I
Geothermal(Heating/Cooling Supply) El Residential Water Supply(single)industrial/Commercial
ft. ft. in.
Residential Water Supply(shared: 18.GROUT
Irrigation rRusl ro ( NI S FRI 0. I NI PI 4rt:S1I Nr'in won&4nr Ot'N r
Non-Water Supply Well: 0 ft. 20 ft. Bentonite Pumped
Monitoring ▪Recovery ft.
ft. Top with Bentomute chips
Injection Well: -
ft. ft.
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery • Salinity Barrier FROM TO MS I ERr1l. 1;MPr..)cr VT.�I SI r:nu1D
Aquifer Test ❑Stormwater Drainage ft. It.
Experimental Technology IDSubsidence Control ft. tr.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM- To DE.SCRII''I'ION(color,hardness,wil/rock type.groin tin,etc.)
D0 it. 63 ft OVER BURDEN t�^ �•
4.Date Well(s)Completed:4-24-2024 Well ID# 63 B 245 ft• GRANITEft. ft.
1 . i+. ,Y V
5a.Well Location:
JUN 1 2 2024
CATHERINE BROOKS ft. rt.
Facility/Owner Name Facility ID#(if applicable) ft. ft. Ifi(�{jfT.:Q•,. i, .)rE�ti U
163 CEDAR HILL ROAD ASHEVILLE,NC ft. ft.
Physical Address.City,and Zip ft. II.
BUNCOMBE 9618985832 11.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ---(if well field,one Iat/long is sufficient) 22.Certification:
N W 5-5-2024
6.Is(are)the well(s)0Permanent or ®Temporary Signa a of(er ed ontractor Date
By signing dh orm.I hereby certifj'that the,w•Il(s)w'as(were/constructed in accordance
7.Is this a repair to an existing well: D Yes or ONo with 15.4 NCAC 02C.1)100 or 15A NCAC 02C.'.0200 Well Construction Standards and that a
//'this is a repair.fill out known well construction information and etplaitt the nature of the coin'of this record has been provided to the well owner.
repair under 021 remarks section or on the hack oil/lit farm.
23.Site diagram or additional well details:
R.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: 245 (ft•) 24a.for All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-301,1200'and 2(d,@1(N)') construction to the following:
10.Static water level below top of casing:60 (ft.) Division of Water Resources.informafion Processing Unit,
',inciter level is above rasing,use"-+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6'25 (ill.) 24b. For Iniection 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
I 3a.Yield(gpm) 5 Method of test: RIG 24c.For Water Supply&Iniection Wells: In addition to sending the form to
PILLS the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 25 completion of well construction to the county health department of the county
where constructed.
Form CIW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016