GW1--03545_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' s,:`;
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
ft. ft.
NC Well Contractor Certification Number 15.01 I ER CASING(for multi-cased wells)OR LINER(If ap licable)
CLYDE SAWYERS&SON WELL&PUMP INC PROM FO DI AMP:TER FDICKNP:SS M4IERIAI.
+1 ft. 56 ft. 6.25 #21 PVC
Company Name ,§in 1 L t•SING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 2022-00441 FROM TO 111111E 1ER chic KN1 S\ 0 U tLRIAL
List all applicable well construction permits tie.UIC,County.State.Variance.etc.)
ft. ft. in.
ft ft. in.
3.Well Use(check well use):
Water Supply Well:
i^.SCREEY
i RovI TO DI SMI I 0 sl 01'�[Lr I'IncKNEss St4Tr:RI St
Agricultural DMunicipal/Public it. it.
in.
Geothermal(Heating/Cooling Supply) 3 Residential Water Supply(single)
Industrial/Commercial
Irrigation
Non-Water Supply Well:
ft. fr. in.
®Residential Water Supply(shared) IS.GROUT
P'KU\I O \141'P'.RISI I,Nip'A('FMFN'T\IFInOD&A\IOl'N'�
0 ft. 20 ft. Bentonite Pumped
Monitoring ®Recovery ft. ft. Cap Top with Bentomite chips
Injection Well: ft. ft.
Aquifer Recharge ®Groundwater Remediation
I4.SAND/GRAVEL PACK(if apPliebhle)
Aquifer Storage and Recovery ®Salinity BarrierFROM TO 5IATERL\:, EMPLACEMENT METHOD
Aquifer Test DStonnwater Drainage _ ft. ft.
Experimental Technology 0 Subsidence Control ft. ft.
]Geothermal(Closed Loop) ®Tracer
20.DRILLING LOG(attach eddihanaY sheets if necessary) .'
`
FROM TO DESCRIP'I ION(color,hardness,soft roe type.grain sire,etc.)
Geothermal(Heating/Cooling Return) ®Other(explain under#21 Remarks) 0 ft ft. OVER BURDEN
4-17-2024 56 ft. 645 ft GRANITE
4.Date Well(s)Completed: Well ID# ft. ft. 6! r `. '-'r
5a.Well Location: RE Le L..11: E L
JEROME WILLIAMS ft. D.
Facility/Owner Name Facility 1D#(if applicable) ft. ft. JUN 1 2 ZOZ4
849 GLEN BRIDGE ROAD MILLS RIVER, NC 28759 ft. ft.
Physical Address,City,and Zip ft. ft. of 1C4
BUNCOMBE 96336532490000 21.REMARKS '
County Parcel Identification No.(PIN) WFLI WAS SFI F CFRTIFIFfl
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
N W i ao-‘,2bzy
6.Is(are)the well(s)D Permanent or ()Temporary Signs a offer ed onlraclor Date
By signing th brow.I hereby certi/i•that the well(s)was(were)constructed in at:cm-dance
7.Is this a repair to an existing well: ©Yes or 0No with 15A NCAC 02C.0/t0)or 1SA NCAC 02C.02(H/Well Construction Standards and that a
If this is a repair..fill out known well construction irnfonnation and explain the nature of the copy of this record has been provided to the well owner.
repair under#1I remarks section or on the hack of this firn,. 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 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: 645 (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 2(d:100') construction to the following:
10.Static water level below top of casing: 10 (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) 100 Method of test: RIG 24c.For Water Suooly&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: 35 completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016