GW1--04758_Well Construction - GW1_20240812

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers -14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. it.
4471-A ---- -a
ft. fr.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER(if ap usable)
CLYDE SAWYERS & SON WELL & PUMP INC FROM TO DI.AND;IER rnICKNESS MATERIAI.
+1 ft. 70 ft. 6.25 in. #21 PVC
Company Name
WeI2024-00040 16.INNER CASING OR TUBING(geothermal closed-loop) _
2.Well Construction Permit# FROM I0 DIAbil/IER IRIC'NESS MATERIAL
List all applicable well construction permits ti.e.UIC.County,State.Variance.etc) ft. ft. In.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: _ %.
PP FROM 10 n1 1kME1 FR _SLUT�In' TOIL K\ISS MATERI SI
°Agricultural Municipal/Public ft. it. in.
°RGeothermal(Heating/Cooling Supply) Residential Water Supply(single) fr ft in -____
industrial/Commercial °Residential Water Supply(shared) 18.GROUT
Irrigation FROM r0 NIArF.Rla1. I.NIP!,A('EMENINIVI1101)&Anion\r
Non-Water Supply Well: o ft. 20 ft. Bentonite Pumped
°Monitoring ®Recovery ft. ft. Cap Top with Bentomite chips
Injection Well:
ft. ft.
()Aquifer Recharge ®Groundwater Remediation
19,SAND/GRAVEL PACK(if applicable)- :%.14 z•15e.
°Aquifer Storage and Recovery ©Salinity Barrier FROM TO MAFERI.SI. i:a1PIACEMEVTMETHOD
°Aquifer Test 0 Stonnwater Drainage ft. ft.
°Experimental Technology [3 Subsidence Control ft. ft.
°Geothermal(Closed Loop) °Tracer .,DRILLING LOG(attach additional sheets if necessary)
°Geothermal(Heating/Cooling Return) °Other(explain under(/21 Remarks) FROM TO DESCRIPTION(color,hardness,soiVrock type.grain size.c1c.)
0 ft. 70 ft• OVER BURDEN
4.Date Well(s)Completed:6-11-2024 Well iD# 70 ft• 165 ft' GRANITE
ft. ft.
5a.Well Location:
SHEILA KILBY ft ft. s,1. .,,..•• '. ' ,1, .,,i
H,ility/Owner Name Facility ID#(if applicable) rt. ft. 4 U G 1 2
89 ISRAEL ROAD CANDLER, NC 28715 ft. ft. 2024
Physical Address,City,and Zip ft. ft. � -r yy ? t
BUNCOMBE 8695390337 21.REMARKS t s ti QI
i
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 7-1-2024
6.Is(are)the well(s)Jtt Permanent or ®Temporary Signa a ofCet cd entractor Date
By signing th arm.I hereby cerr*that the well(a)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or DM) with 15.4:NCAC(12C.0/1XI or 1SA NCAC(12C'.0201)Well Construction Standards and that a
If this is a repair/Ill out known well construction inlinrmaiion and explain the nature of-the copy of this record has been provided to the well owner.
repair under ft21 remarks section or on the back of this.form.
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: 165 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-30).200'and?(a;/O(I') construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,information Processing Unit,
Iwater level is above casing use'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 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
13a.Yield(gpm) 20 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: 20 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