GW1--03534_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.WATERZO ES _
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A -1
IL ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if ap icable)
CLYDE SAWYERS&SON WELL & PUMP INC FROM TO uI.sr,IETER 'THICKNESS I MAITRIAL
+1 ft. 30 ft, 6.25 in. #21 PVC
Company Name -
WEL2023-00109 16.INNER CASING OR TURING'(geothermal closed-loop) `
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL _
List all applicable well construction permits(i.e.UIC County,State.Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM to DI tMEI FR SI 01 SIZE tIlICKNFSS NIA II RI 0
°Agricultural ®Municipal/Public ft. it. in.
OGeothemtal(Heating/Cooling Supply) Q Residential Water Supply(single) it. h. in. .--
industrial/Commercial ®Residential Water Supply(shared) 18 GROUT
Irrigation I'RO'I ru MS FRISI ' I•MytWI\n\I Nit ln0D&A0OINr '
Non-Water Supply Well: 0 ft. 20 ft. Bentonite Pumped
()Monitoring °Recovery ft. ft. Cap Top with Bentomute chips
Injection Well:
ft. tit.
(:3Aquiter Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery O Salinity Barrier FItt1\I TO II S I ERLV. E'MPI,ACEME.NT METHOD
0Aquifer Test °Stonnwater Drainage ft. ft.
°Experimental Technology °Subsidence Control II. ft.
°Geothermal(Closed Loop) °Tracer I0.DRILLING LOG(attach additional sheets if necessary)
DGeothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hanlncxs soil/rock type.Quin size,etc.)
0 ft. 30 ft• OVER BURDEN
F
3-11-2024 ft ft. 'F'' "'"4/
; /c r .
4.Date Well(s)Completed: Well ID# 30 805 GRANITE �% J i„y' V L. i
5a.Well Location:
ft. ft. JUN 1 2 2024
3 ROCK LLC ft. ft.
ft. ft. ifi�ti0Atiif tl f r��iAp;:r URt
Facility/Owner Name Facility ID#(if applicable) t _ +�
343 GARREN CREEK ROAD FAIRVIEW, NC 28730 ft. ft.
Physical Address,City,and"Lip ft. ft.
BUNCOMBE 969663113400000 21.REMARKS ="r
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 A' 3-20-2024
6.Is(are)the well(s)�t Permanent or OTemporary Stgna e of e ed onlraclor Dale
By signing th orm,/hereby cerrij'that the well(s)avts(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or EINo with 15.4 NC'AC 02C.0/00 or 15A NCA(2 02C.0201)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 sell owner.
repair under#21 remarks section or on the back of this form.
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 OW-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: 805 (R•) 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(a 100) construction to the following:
10.Static water level below top of casing:240 (ft.) Division of Water Resources,Information Processing Unit,
I/'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
PILLS the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 35 completion of well construction to the county health department of the county
where constructed.
Form CrW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016