GW1-2021-01534_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
HEATH SAWYERS 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2436-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING'for multi-cased wells ORILINER if 21' icable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 58 ft- 6.25 '" #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed too
20100121231 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well perntil.v(i.e.County,Stale,Variance,Injection,etc)
ft. %
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) l7lResidential Water Supply(single) f. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT, '
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 1 Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANWGRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recover), ❑Salinity Barrier ft. ft.
❑Aquiter Test ❑Stormwater Drainage
rt. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional Sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 58 ft. OVER BURDEN
1-29-2021 58 a• 565 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
Sonia Garrett ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. /t u (� O�
Pharis Place Hendersonville, NC 28792 ft. ft. hilt' Y
Phvsical Address,City,and Zip 21REMARKS" (on ProCes;Oly Unit
Henderson 9673913254 DWR Section
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field one]at/long is sufficient)
N `,1, �I �.�. �J� 2-24-2021
Signature of Certified Well Contra Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By.signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy o/this record has been provided to the well owner.
ll this is a repair.,Jill out known well construction information and explain the nature gflhe
repair under;-21 remarks section or on the hack q/'Ibis 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.
hbr nudliple injection or non-waler.supply wells ONLY with the same construction,you can
.suhmit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 565 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
1,or multiple wells list all depths tJ different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 60 (ft•) Division of Water Resources,Information Processing Unit,
l/baler 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 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(gp ) 24c.For Water Supply&Injection Wells:
m 2 Method of test: RI
Also submit one copy of this form within 30 days of completion of
PILLS
13b.Disinfection type: Amount: 35 well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013