GW1--05593_Well Construction - GW1_20240916

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: li
1.Well Contractor Information:
Kolby Mitchel Sawyers <-14' R WATEZONES£.2„ i
�FROM ' TO DESCRIPTIONI
Well Contractor Name
4471-A n. ft.
ft. rt.
NC Well Contractor Certification Number i5i OVTERCASCNtr(fur.miiltt ens iltiVO)t)OR LONER(if appheahle) M'
CLYDE SAWYERS &SON WELL& PUMP INC FROM To DIAMETER THICKNESS 1 MATERIAL
+1 ft. 75 ft. 6.25 ,in: #21 PVC
Company Name
2024-00154 .16ANNEWCASING oR TURI G7(gegtitertntiIclnsed liiO0
2.Well Construction Permit#: FROMTO 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. s in.
Water Supply Well: 7-17°SCREEN.. ti ... `,-
FROM TO
DIAMETERSLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothemial(Heating/Cooling Supply) Residential Water Supply(single) H. H. in. ,
Industrial/Commercial ()Residential Water Supply(shared) 413:GROUT .._ t ,` 5,,a . .R.w „;,; ;._-. ',F:,
Irrigation _FROM TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite Pumped
Monitoring Recovery ft.
ft. ft. Cap Top with Bentomite chips
Injection Well: • ft.
Aquifer Recharge Groundwater Remediation
19,SAND/GRAVEL PACK(if applleable)a
-Aquifer Storage and Recovery QSalinity Barrier FROM TO MATERIAL - EMPLACEMENT METHOD
Aquifer Teat IStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20:DRILLING LOG(atttichtidditidniil=sbeeis ifnecessary) <°% ,. '^1>1
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 ft. 75 ft. OVER BURDEN
09-04-2024
4.Date Well(s)Completed: Well ID# 75 ft. 325 ft' GRANITE
Sa.Well Location: ft. ft. - ..t ,•,•.''
DOMO CONST.LLC/2020 BUILDERS ft. ft. (+[' ' V 4�•tLi
Facility/Owner Name Facility lD#(if applicable) ft. ft. , SEP 1 6 2024
32 LITTLE OAK RD LEICESTER, NC ft. ft.
ft. et- i, is Tr,s; : , .Per, Ito
Physical Address,City,and Zip CANCd
BUNCOMBE 97031133050000 ,21:'REMARKS.. . H. ,O,A'W_,4�_'r,. 6n, s_< 4,
g
County Parcel Identification No.(PIN) I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N `V 09/11/2024
6.Is(are)the well(s)e)Permanent or Temporary Signs a offer ed ontractor Date
By signing th.film,I hereby certifj,that the well(s)ieas(mere)constructed in accordance
7.is this a repair to an existing well: DYes or EtNo with 15A NCAC 02C.0100 or 15A NCAC';02C.0200 Well Construction Standards and that a
If this is a repair,fill out/smart well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair render#21 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: 1 SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: 325 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list al/depths if different(example-3@200'and 2@100) construction to the following: ,
10.Static water level below top of casing:45 (ft.) Division of Water Resources,information Processing Unit,
if water level is above casing,use"+" 1617 Mail Service CenIter,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 thiq form within 30 days of completion of well
12.Well construction method:
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:_
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 8 Method of test: RIG 24c.For Water Supply&Infection Wells: in addition to sending the form to
PILLS the address(es) above, also submit 11one 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 GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016