GW1--05594_Well Construction - GW1_20240916

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i '
1.Well Contractor Information: l
_' '
Kolby Mitchel Sawyers
;14.`WA1'E1t1ZCiNRSA-� . `^`s1=.. _ _ , s
Well Contractor Name FROM To DESCRIPTION I
4471-A ft. ft. I
ft. ft. ;
NC Well Contractor Certification Number 1.5,;OUTRR:GASING,{far iriiilti r tsedasells)OR JLiNER,(ifip`Uc able);°% .
CLYDE SAWYERS & SON WELL & PUMP INC FROM To DIAMETER' . THICKNESS MATERIAL
+1 ft. 72 ft. 6.25 I,in. #21 PVC
Company Name FROMNER C S NG OR-T DIAMETER THICKNESS MATERIAL ..
2024-00155tslNG(�c`F�fnertt;al=crused taapt,�.`§ ,
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UJC,County,State,Variance.etc.) ft. ft. :,in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: L7./SCREEN2 o" ,as, ,ky ,Z :,;l ;, :.,•4 E. -"...
FROM TO DIAMETER :SLOT SIZE THICKNESS MATERIAL
1 Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EPResidential Water Supply(single) ft. ft. in. '
*Industrial/Commercial DRcsidential Water Supply(shared) ;,1g.GRotiv``..: °°T,_ x_8, -0� � , , ,`
i Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite Pumped
*Monitoring Eintecovery ft. ft. r Cap Top with Bentomite chips
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
• 19:;SAND(GRAVEI1'ACK:(if applicable) , . o ). a;
I Aquifer Storage and Recovery 0 Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
*Aquifer Test DStonnwater Drainage ft. ft.
MI Experimental Technology OISubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer •20 DRILLING`COG:(attach'additioriat"Sheets.ifnecessary), .. r. it
11 FROM TO SCP (
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 ft. 72 ft. OVERDERI BURDEN TION color.hardness,suit/rock type,grain size,etc.)
09-05-2024
4.Date Well(s)Completed: Well ID# 72 fL 245 ft• GRANITE 17.7)(r^^<<, ,
5a.Well Location: ft. ft. �,f..•..0�ry 4 V 1
DOMO COAST.LLC/2020 BUILDERS ft. ft. I' SEP P 1 6 2024
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Facility/Owner Name Facility lD#(if applicable) ft. ft. i
38 LITTLE OAK RD LEICESTER, NC ft. It. lr ;I^.a; .,Z i+rtara, ,,2,g Uik
Physical Address,City,and Zip
ft. ft. C+ C,:i2OG
BUNCOMBE 9703112291000
.21fREMARI{g'`^):': , , ,rt _,:.; ,,, ;....__-_ex t. c, `»,
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 `v 09/11/2024
6.is(are)the well(s)a iPermanent or EiTemporary Sigma c ofCe edllt
ontractor Date
By signing lh.fain.1 hereby certify that the well(s)was(were)constructed in accordance
7.is this a repair to an existing well: IIYes or XoNo with 15A NCAC 02C.0100 or 15A NCAC)2C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction inlbrmatiou 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 back o(this farm. .
23.Site diagram or additional well details:
3.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 1
9.Total well depth below land surface: 245 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list al/depths ifdiiferent(example-3L 100'and 1 a 100) construction to the following:
6
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10.Static water level below top of casing: 50 (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.) lI
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:
II
(i.e.auger,rotary,cable,direct push,etc.)
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Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) 7 Method of test: RIG 24c.For Water Supply&Injection Wells: in addition to sending the form to
PILLS the address(es) above, also submituone copy of this form within 30 days of
13h.Disinfection type: Amount: 18 completion of well construction to,the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016