GW1-2021-01535_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: RECEIVED
14.WATERZONES
KOLBY SAWYERS
FROM TO DESCRIPTION
Well Contractor Name MARft. ft.
4471 A ft. ft•
+ntormat�on Processing Unit
NC Well Contractor Certification Number DWR Section 15hOUTER CASING for multi-cased wells OR LINER if a"""Iicable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 45 rt• 6.25 #188 Steel
Company Name 16.INNER CASING ORTIJBING eothermalclosed-loo
20100119951 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +1 ft. 46 fr. 4 in. #21 PVC
List all applicable well permits(t.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
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
El ❑ 18.GROUTResidential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[ Irrigation 0 ft' 20 ft- Bentonite Pumped
Nun-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.-SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test ❑Stotmwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.rDRILLING LOG attachadditional sheets if necessa
❑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- 45 ft. OVER BURDEN
2-24-2021 45 ft• 165 ft- GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
THOMAS SPRIGGS ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
757 CRAB CREEK ROAD HENDERSONVILLE ft. ft.
Physical Address,Citv,and Zip 21.<REMARKS., ,.ate:.., .......��,
HENDERSON 9546434735 Installed 4"liner pipe&packer Per County
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 W 'Okn 0& a go&4 �_ 3-4-2021
rttt Signature ofCeed Contracto Date
6.Is(are)the w'ell(s): ©Permanent or ❑Temporary By signing this farm,I hereby certify that the well(s)was(mere)constructed in accordance
with I5A NCAC 02C.0I00 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofthis record has been provided to the well awner.
l/1his is a repair,fill out known well construction information and explain the nature of the
repair under o21 remarks section or on the back o.0his 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.
hhr multiple injection or non-water supply wells ONLY with the sante construction,you can
submit one form. SUBMITTAL INSTLICTIONS
9.Total well depth below land surface: 165 (1t•) 24a. For All Wells: Submit this form within 30 days of completion of well
hbr multiple a e/lv list all depths i/'different(example-3 r@i 200'and 2 a@100') construction to the following:
10.Static water level below top of casing: 30 Division of Water Resources,Information Processing Unit,
If rater level is above casing,use"{" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY: In addition to sending die 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.field m 15 Method of test: RIG 24c.For Water Supply&Injection Wells:
(gp ) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 20 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