GW1--06716_Well Construction - GW1_20241108

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
7114."WATER ZONES -. r ' x _. �-'''' .�a,e,,,-
Derrick Heath Sawyers FROM TO DESCRIPTION I
Well Contractor Name ft. ft. I
2436-A ft. ft.
NC Well Contractor Certification Number ''I5.OUTER°CASING(for much-cased•wells)()WEINER pp Leable)- r
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL& PUMP INC +1 ft- 62 ft- 6.25 in' #21 PVC_
,.MANNER CASING OR-TUBING(l;ebthermal closed loop).V'1``". ,. 9 ,..„�.
Company Name :'•
2023-00339 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. io.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft ft. in.
3.Well Use(check well use): 17,SCREEN '
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public .
❑Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ,-IFLGROUT . -, .: ,` .•-'` _ °�
FROM TO d• MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft.. ft. Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation -19.SAND/GRAVEL PACK.(If abpllcahle) ' • <-, _ _
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.,DRILLING=LOG(attach additional sheets if necessary) ":r;, ., , : I' ., : =
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,Frain size,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft. 62 ft* OVER BURDEN
10-23-24 62 ft- 245 ft. ~- "_GRANLTE; ;:-...,-,.
4.Date Well(s)Completed: Well ID# ft. ft. ` '� _'L > j,: el
5a.Well Location: ft. ft. N O V 0 8 2(12 4
R&S INVESTMENTS OF WNC,LLC ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. • it,w r„ .i.<;;`crn\c2,tt a--;a t t
IDIAN PAINT BRUSH LOT#41 ft_ ft. D`` `
Physical Address,City,and Zip
,,21 REMARKS.r:F -, -. ,'. ,,..-', , :, , u. ` ., ., c, h d
Buncombe 972126357700000 WELL WAS SELF CERTIFIED
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 N 10-23-2024
Signature of edifie' d Well Contracto Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1SA 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 ENo 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 1121 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 i
submit one form. SUBMITTAL INSTUCTIONS I
depth below land surface:9.Total well 245
(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 2Ca 100) construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY:J hi 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
13a.Yield(gpm) 1 00 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 20 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