GW1--05595_Well Construction - GW1_20240916

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: f
1.Well Contractor Information:
Kolby Mitchel Sawyers WATEIxZONES 4 :o —7 , ; M''1:
FROM TO DESCRIPTION!
Well Contractor Name ft. ft.
4471-A
ft. ft.
NC Well Contractor Certification Number f tStOlITER L'AS1NC4-itor<'muld case[taRellsMeftINER'(ifI )teilh14 ;`•;�
CLYDE SAWYERS & SON WELL & PUMP INC FROM TO DIAMEtERI I THICKNESS MATERIAL
+1 ft. 76 ft. 6.25 to #21 PVC
Company Name ...._ �> s ;
WEL2024-00200 .t6,hiNNER,CASFl!i, o)iTUBII�G(acutlrerma)�closert,toop � a W, ,-
2.Well Construction Permit#: FROM TO _ DIAMETER, THICKNESS MATERIAL •
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. ;in'. .
3.Well Use(check well use): ft. ft. in.
iti:Water Supply Well: FROM TO DIAMETER ' SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in. '
Geothermal(Heating/Cooling Supply) BResidential Water Supply(single)industrial/Commercial
ft. ft. in. `
Residential Water Supply(shared) i8:GR0[1.T � � ,� ��t '
irrigation _ FROM TO MATERIALPI.ACE MEN"r METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 tt• Bentonite Pumped
Monitoring Recovery ft. ft. Cap Top with Bentomite chips
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test fStonnwater Drainage ft. ft.
BExperimental Technology Subsidence Control ft. ft. .
Geothermal(Closed Loop) OTracer 3baDRILLGfT{1Gtivacli'addiHanatshetsCinecessaty}. �MME
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FROM TO DESCRIPTION(color,hardness,soil/rock type.groin size.etc.)
Geothermal(Heating/Cooling Return) Other(explain under#2]Remarks) 0 ft. 76 ft. OVER BURDEN
4.Date Well(s)Completed:9-3-2024 Well ID# 76 ft. 165 ft GRANITE R"-
5a.Well Location: ft. ft. •,��• i..-�4,f i� Y)
LOREN LUSK ft. ft. SEP 1 „
Facility/Owner Name Facility ID#(if applicable)
ft. ft. 2024
13 RUFF ROAD LEICESTER, NC 28748 ft. ft. Ink.: '+fr'.bf.,'; fir<rw.,...�.,a,,1
�.... Jar
Physical Address,City,and Zip ft. ft.. Q+v�.a
BUNCOMBE 87918383860000 11 IEM'BIi80", �• W W1 ore. ',,':',V40
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: I.
N W 9-10-2024
6.Is(are)the well(s) Permanent or0. Temporary Sigma a of et ed milt-actor DateX
By signing th brm,1 hereby certifj.that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or X©INo with 15,4 NCAC 02C.0100 or 15A NCAC 02C'.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 back of this firm.
23.Site diagram or additional welfdetails:
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-3@,200'and 2@l00') 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 Ceinter,Raleigh,NC 27699-1617
6.25 11
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
ROTARY above,also submit one copy of thin form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger.rotary,cable,direct push,etc.) I,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I
13a.Yield(gpm) 25 Method of test: RIG G
24c.For Water Supply&Injection Wells: In addition to sending the form to
PILLS the address(es) above, also submit)oite copy of this form within 30 days of
13b.Disinfection type: Amount: 20 completion of well construction to'kite county health department of the county
where constructed,
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016
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