GW1-2021-01533_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
KOLBY MITCHELL SAWYERS FRONII�l TO O � �... .
FRONT TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number t5-.UUT1t-C ikS fnraltl;cas tivc[fs A)R fstNEult i lteabie`'
FROM TO DIAMETER TTHCKNF.SS I MATERIAL
CLYDE SAWYERS AND SON WELL +1 ft. 30 ft. 6.25 in- #21 PVC
Company Name Eti.Jl!1t�7faR- ee1NO.UtI.Tt7lI1N
20120108653 FRONT .1'0 DIAMETER THICKNESS N1 A'1'ER[AL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Coumv,State,Variance,Injection,etc,) ft. ft. in,
3.Well Use(check well use): t
r- - ...... ---- -------
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) EIResidential Water Supply(sin(single) it. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) f Rt)>ElT �, `� --------------
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑TITi ation 0 ft. 20 ft. BENTONITE PUMPED
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation .,S2S1ltI)l(xRi15EL3' t li da` 'mile
--
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardnes soil/ ck tv a min size,etc.)
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 ft' 30 ft• OVER BURDEN
ft. ft.
4.Date Well(s)Completed: 01/22/2021 Well ID#
30 ft 545 ft GRANITE
5a.Well Location: ft. ft.
Walter Keyser
Facility/Owner Name Facility ID#(ifapplicable)
415 Big Willow Rd, Hendersonville ft. ft.
Physical Address,City,and Zipt �� x-
Henderson 9621969718 h-- _:
County Parcel Identification No.(PIN)
InformationProcessing Unit
5b.Latitude and Longitude in degrees/minutes/seconds or.decimal degrees: 22.Certification- DW R Section
(ifwell field,one lat/long is sufficient)
N 02-25-2021
WSw- -1fiedV.t[!Contras Date
6.is(are)the well(s): ❑✓Permanent or ❑Temporary By signing this fenm.I herehr c %Y that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 nr 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or ❑No copy ofihis record has been provided to the well owner.
Ijthis is a repair,fill out knourr well construction information and explain the nature of the
repair[order#21 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface• 545 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if di/ferent(example-3(4i�200'and 2(a,,100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
Ifwmter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
ROTARY AIR 24aabove, 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) 15 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days ofcompletionof
13b.Disinfection type: Amount: 35 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