GW1--05597_Well Construction - GW1_20240916

ENTA rot 11I g
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Kolby Mitchel Sawyers ata: ATL� .,u.. .'4 M:,;':' '' , k
FROM TO DESCRIPTION!
Well Contractor Name
4471-A ft. ft.
fL ft. 1
NC Well Contractor Certification Number 8 tgAitAgttiMiiiiG(ftirmtilti..cagitti4110)VE 1\`Cr tL.(1rap icatiteM ''z.,,`r*`fit
CLYDE SAWYERS &SON WELL & PUMP INC FROM TO DIAM KIERI . THICKNESS MATERIA1.
+1 ft. 74 ft. 6.25 in #21 PVC
Company Name -.=
WEL2023-00244 «ts,.lrrtiER,C tit!acir�;EUB1Nc:ter o t iui1°elosed,tQ a Si
2.Well Construction Permit#: FROM TO " DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Coun(s,State,Variance,etc.) fL ft. in.
3.Well Use(check well use): it, ft. in•
Water Supply Well:
Agricultural 0Municipal/Public
f2;SORREN ' ai '. ., 7a.� k '4, R w4r.�e,
pp FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
fL ft. in.
Geothermal(Heating/Cooling Supply) ' EResidential Water Supply(single)industrial/Commercial
fL ft. in.
Residential Water Supply(shared) l$ G Rd11T * i � ,F111
4
irrigation FROM TO MATERIALEMPLACEMENT METHOD&AMOUNT'
Non-Water Supply Well: 0 fL 20 ft- Bentonite+ Pumped
Monitoring �E Recovery ft. ft. Cap Top with Bentomite chips
Injection Well:
ft. ft.
Aquifer Recharge ®Groundwater Remediation
WSAI D. /C.K/N8it PACK t ftRillaItle}. M M. VM '_.0 '
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test El Stonnwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft
Fr3Geothermal(Closed Loop) 0 Tracer Sit 12i>j1;;Nt ti (atiaehtaidiliti a" heets ken cessai} , 4E4400,,
Geothermal(Heating/Cooling Return) [3 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,eta)
0 fL 74 ft. OVER BURDEN
4.Date Well(s)Completed:8-29-2024 Well ID# 74 ft. 525 ft. GRANITE
5a.Well Location: fL ft. ( .. `y
THOMAS AMES ft. ft. ` 4([P
` "' 1��r�'Facility/Owner Name Facility ID#(if applicable) ft. ft. v G 1 b Z024
MERREL ROAD LEICESTER, NC 28743 ft. ft. la;,n-zef,, 9s„,.,j a
•
Physical Address,City,and Zip ft. ft.. etViCa0a
BUNCOMBE • 8792752801 4,1T 13Et41"Ai21 °"'x. .,. '.-kAggeglatr=r4AWei
County Parcel identification No.(PiN) i'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: it
(if well field,one lat/long is sufficient) 22.Certification:
N w 9-6-2024
6.Is(are)the well(s)I�IX Permanent or Temporary Signa e of er ed onhuctor ° Date
By signing th brrn,I hereby cer•tifj•that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0 Yes or 1:11No with 15A NCAC 02C.0100 or I5A 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 1121 remarks section or on the back of this form. i
23.Site diagram or additional well details: ,
8.For Ceoprobe/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 I 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: 525 (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(a 100) construction to the following:
li
10.Static water level below top of casing: 80 (ft.) Division of Water Resources;information Processing Unit,
I/'water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
6.25 I '
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 this'form within 30 days of completion of well '
12.Well construction method: construction to the following: l'
(i.e.auger,rotary,cable,direct push,etc.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centel,Raleigh,NC 2 76 99-1 63 6
13a.Yield(gpm) 4 Method of test: RIG 24c.For Water Supply&Iniectiori Wells: In addition to sending the form to
the address(es) above, also submit one copy of'this form within 30 days of
13b.Disinfection type: PILLS Amount: 35 completion of well construction to the!county health department of the county
where constructed. i 1
i
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources • Revised 2-22-2016
i,