GW1--06688_Well Construction - GW1_20241108

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information: •
Kolby Mitchel Sawyers 44. ►ATEIV ES . ,Ww ,t ;
FROM TO DESCRIPTION
Well Contractor Name ft ft. I.
4471-A l'
ft. ft.
NC Well Contractor Certification Number Qi5 (TE[2eXSINGtfors`tiiuldba5ciltivelli)OftTdNEI2'(i p Ilcaiite) k a`u',a``vv
CLYDE SAWYERS & SON WELL & PUMP INC FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. 63 ft. 6.25 I in. #21 PVC
Company Name
2024-00273 i6.�°,ltv(V);ReCA INN IIVIIlsll,G ofhermatr eiFITOp s .
2.Well Construction Permit#: FROM TO DLAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
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3.Well Use(check well use): ft. ft. in.
Water Supply Well: • 1.7::5GREENFn.. .; .. ss ',
FROMTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft.
in.
Geothermal(Heating/Cooling Supply) ta Residential Water Supply(single) — ft.industrial/Commercial
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irrigation
ft. in.
Residential Water Supply(shared) k t$ GROUT � �� x4 _ ":'
FROM TO 'MATERIALEMPI,ACFMF:N"r METHOD&A\IDUN9'
Non-Water Supply Well: 0 ft. 20 ft. Bentonite . Pumped
Monitoring • Recovery ft. ft. Cap Top with Bentomile chips
Injection Well: —
ft. it.
Aquifer Recharge 0Groundwater Remediation
®Salinity Barrier
' TIAVEIs"'PACE(if aiVlicutile)VX b �; '
Aquifer Storage and Recovery FROM TO
MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stonuwater Drainage ft. ft.
Experimental Technology IDSubsidence Control ft. ft. i
BGeothermal(Closed Loop) 0Tracer <2(I t)I2 LI11 I1G{iiiarl addiiipt?al beets itaiecessa> ��a �
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
• Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks) 0 ft 63 ft. OVER BURDEN
4.Date Well(s)Completed: 9-9-2024 Well ID# GRANITE
63 ft ft.
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Sa.Well Location: ft ft i '. "" c_,; "_ ;'
t. "-` +f, ' �'°"'`
WILLIAM TREXLER ft. f •
Facility/Owner Name Facility ID#(if applicable) ft. ' ft. , r`q IV i► 8 ZUZ4
42 TRIPLE OAK CANDLER, 28715 ft. ft. ,[;,/e
Physical Address,City,and Zip ft. ft. 0, a`;r; ,J:3 -
, BUNCOMBE 869770276000000 =21:YR1~1v1ARK.S k A. arO M._ ' . .,, mr;
County Parcel ldentitiationNo,(PIN) WELL WAS SELF CERTIFIED
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell field,one lat/long is sufficient) 22.Certification: ,
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N VI' -� 1- IS-a ay
Signs
6.Is(are)the well(s) Permanent or Temporary
of er edl5lejlj�onlmdor Date
x
By signing th Orin,I hereby cerr/fi'that the well(s)was'(were)constructed in accordance
7.Is this a repair to an existing well: 0 Yes or xoNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair.Ill 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 form.
23.Site diagram or additional well details:
S.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: t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 (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 cy/.00') construction to the following:
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10.Static water level below top of casing: 40 • (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.
) 24b.For Iniection Wells: In additi I 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) 30 Method of test: RIG 24c.For Water Supply&Injection'Wells: In addition to sending the form to
the address(es) above, also submit tine copy of this form within 30 days of
13b.Disinfection type: PILLS Amount: 30 completion of well construction to thle county health department of the county
where constructed. •
Form OW-i North Carolina Department of Environmental Quality-Division of Water Resources • , Revised 2-22-2016