GW1--03536_Well Construction - GW1_20240612

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ko by Mitchel Sawyers 14.WATER ZONES
FROM l0 _ DESCRIPTION
Well Contractor Name ft. ft.
4471-A -- - -
I it. ft.
NC Well Contractor Certification Number 15.0C1ERA:NSI\G(Ow multi-eased wells)OR LINER(if applicable)
CLYDE SAWYERS& SON WELL & PUMP INC FROM 10 I)IA1IIF,TER THICKNESS M4T ERIAI
+1 rt. 170 ft. 6.25 in. #21 PVC
Company Name
We12024-00065 11,.INNER( SING OR Tt1IINC(gent her itaI closed-I„gpj
2.Well Construction Permit#: FROM TO DL>,ME rER rlifc ENLSS MATERIAL
List all applicable well construction permits(i.e.UIC,Con, I State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): n ft. in.
Water Supply Well: — 17.SCREEN
FROM "f0 DI4MF:TER _ SLUT SIZE THICKNESS \ISIUtI%I.
Agricultural ®Municipal/Public ft. II. in.
Geothermal(Heating/Cooling Supply) @Residential Water Supply(single) ft. ft, in.
industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO M+rr Rt SI. FMrt AU FAWN c.vr\IF rnoo A�IUI al
Non-Water Supply Well: 0 ft. 20 1't. Benlonite Pumped
Monitoring Q Recovery ft. ft. Cap Top with Bentomile chips
injection Well: — — -
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicably)
Aquifer Storage and Recovery Salinity Barrier FnoM To MATERIAL FRIG, EMI'L.SC EMEN 1 Sn.l HOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology ED Subsidence Control ft. ft.
Geothermal(Closed Loop) 0Tracer 20,DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soibrock hype.grain,i,r.ctc.i
DGeothennal(Heating/Cooling Return) QOther(explain under#21 Remarks)
0 ft• 170 ft• OVER BURDEN
4.Date Well(s) 3-7-2024 Completed: Well iD# 170 ft• 365 ft• GRANITE _
5a,Well Location: ft ft. E .__�" I;°f E
CALVIN CAMBY ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft. JUN 1 2 2024
76 HILL SIDE DRIVE FAIRVIEW, NC 28730 ft ft. Ir &,i Pre ‘rit up*
Physical Address,City,and Zip ft. ft. tyI'Cr 1t.y
BUNCOMBE 06060287120000 21•REMARKS
County Parcel identification No.(PIN) _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(if well field,one lat/long is sufficient) 22.Certification:
N W 3-15-2024
6.Is(are)the well(s)D% Permanent or ®Temporary Signs a of Let ed onlraclor Date
By signing th arm.1 hereby certify that the weeks)was(were)constructed in accordance
7.Is this a repair to an existing well: 0 Yes or EiNo with 15,4.VCAC 112C.01(N)or 1 SA NCAC 02C,(12(N)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 urn owner.
repair under#21 remarks section or on the hack r f 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 GW-I 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: 365 (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 NOV') construction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,information Processing Unit,
If water level is above casing,use••+ 1617 Mail Service Center,Raleigh,NC 2 7699-1 6 1 7
It.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) 5 Method of test: RIG 24c.For Water Supply&Injection Wells: In addition to sending the form to
PILLS the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 3J 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 Revised 2-22-2016