GW1--03555_Well Construction - GW1_20240612

IPrint Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers 14.WATER ZONES
Mom To DI 1('IRIPTIO\
Nell Contractor Name ft. ft.
4471-A
NC Well Contractor Certification Number
15.(II TER CASING(for(multi-cased wells)OR LINER(if ap lcabtt•)
CLYDE SAWYERS&SON WELL&PUMP INC FROM To DIASIe MR THICKNESS MATF:RIAI.
+1 ft• 104 O. 6.25 in- #21 PVC
Company Name
2023-00352 16,INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO IMAME TER THICKNESS MATERIAL
List all applicable well constriction permits ti.e.UIC,County,State.Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. 1O'
Water Supply Well: 17.SCREEN
FROM 10 DIAMF:I FR _c_I.OT size TItICK\FSS MaTr RI AI.
Agricultural ®Mw)icipal/Public 0, ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
PJ g PP Y) � PP y l� 6 ) ft. ft. in.
industrial/Commercial Residential Water Supply(sharedl 1g GROUT
Irrigation rlto,t o >I a rF.Rui. F,i rt +t r,n\I ,I l MOD&+slot\i
Non-Water Supply Well: 0 ft. 20 t't• Bentonite Pumped
Monitoring ®Recovery ft ft. Cap Top with Bentomile chips
injection Well:
ft. ft.
Aquifer Recharge ®Groundwater Remediation Iq,S.aND/ RAVEL.PACK Eifappliwhie)
Aquifer Storage and Recovery Salinity Barrier I.Rt ut To MATERIAL erotPLACEMF.N i'si ruc)D
Aquifer Test DSlomtwater Drainage ft. ft.
Experimental Technology oSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRI1.LINC:LOG(attach additional sheets if necessary)
F'ROrI TO DESCRIPTION(color,hardness.soil/rock type.grin size,etc.)
Geothermal(Heating/Cooliug Return) ElOther(explain under#21 Remarks)
0 ft. 104 ft. OVER BURDEN
4.Date Well(s)Completed:5-8-2024 Well iD# 104 ft. 185 ft• GRANITE
5a.Well Location: ff. ft• '"
Adam Fayssoux ft. ft. R E`_'�. t E['
Facility/Owner Name Facility ID#(if applicable) ft. ft. f J U t 1IV 1 2 2fl24
34 Chaz Lane Candler, NC 28715 ft. ft. W
Physical Address.City,and Zip ft. ft. littertr. 4 it rs-e.r.404 Uif�
Buncombe 9606931696 21.REMARKS DFJAA.r 31v
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W 5-22-2024
6.Is(are)the well(s)0Permanent or OTempurary Signa a offer ed ontracmr Date
Br signing th arm,1 hereby certiJf that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or xDNo with 15.4 NCAC 02C.0100 or ISA NCAC(12C.0200 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 well owner.
repair under#21 remarks section or on the hack of 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-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: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple iveils list all depths if different(example-3(0200'and?WOO') construction to the following:
10.Static water level below top of casing: 30 (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: 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) 20 Method of test: RIG 24c.For Water Supply&)niection 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: completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016