GW1--06715_Well Construction - GW1_20241108

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
• �FR_WATER`°N . - TION' - "
Derrick Heath Sawyers
FROM TO DESCRIPTION'
Well Contractor Name H. ft.
2436-A ft ft. -
NC Well Contractor Certification Number 15 OUTER-CASING(far multi-eased.wells)OR LINER(if app!feeble),,_;; z., ''.,;
FROM TO • DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL& PUMP INC +1 ft• 71 ft• 6.25 in. #21 1 PVC
Company Name ''16.1NNERCASINGOR,TUBING(goo ermal.closed.loop):.•: ,.
2024-00574 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: R. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) -
ft. ft. in.
3.Well Use(check well use): d 17.SCREEN r _ ;<
Water Supply Well: FROM - TO DIAMETER ' SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural OMunicipal/Public
OGeothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑Industrial/Conimercial ❑Residential Water Supply(shared) 18,GROUT �,.+- ,. _.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft• 20 ft• Bentonite Pumped .
Non-Water Supply Well:
H. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation -1.9.SAND/GRAVEL PACK,(if applicable) "" ' _. . .
FROM TO MATERIAL' EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
420z,DRILLING LOG°(a'ttach addititiiiaisbeets if necessary) ^:i_r+..
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness soil/rack type,grain size,etc.) _
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 71 ft• OVER BURDEN
10-25-2024 71 ft• 505 ft• • C RQFTEN ''? ';R s q --
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft. NO V 0 8 20?4
BRIAN BICKEL ft. ft
Facility/Owner Name Facility ID#(if applicable) In`,- -.• -'._
ft. ft �i':tlla;31 r. bJsn
25 CARL ROBERTS ROAD ft. ft.
Physical Address,City,and Zip 21:REMARKS'';_ r., , .1-,,,,a
Buncombe 972101765200000
County Parcel Identification No.(PIN) ',
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one 1at/long is sufficient)
N W 10-30-2024
Signature of edified Well Contmcto l Date
6.Is(are)the well(s): OPermanent or :Temporary
By signing this form,I hereby certifr that the walks)was(were,)constructed in accordance
with ISA NCAC 02C.0100 or 15,1 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes .or No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the .
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well'details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 505 (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@/00) construction to the following:
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 Injection Wells ONLY: 11n,addition to sending the form to the address in
ROTARY 24a above, also submit a 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
RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 5 Method of test:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 30 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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