GW1-2021-06230_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
KOLBY SAWYERS 14.FROM WATER
FROM TO DESCRIPTION
Well Contractor Name ft. fr.
4471-A e. fr.
NC Well Contractor Certification Number 15.OUTER CASING'for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 63 rr• 6.25 1 " #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-too
19120120986 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. fr. in.
l.ict ull applicable urll permits(i.e.County,Slate, 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.❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) l7lResidential Water SuPPIY(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft' 20 ft. Bentonite Pumped
Nun-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.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
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 421 Remarks) 0 ft- 63 ft, OVER BURDEN
6-3-2021 63 rr• 705 rr• GRANITE
4.Date Well(s)Completed: Well ID# fr. ft.
5a.Well Location: fr. ft.
ROBERT ANDERSON
Facility/Owner Name Facility ID#(ifapplicable)
TRAMMELL GAP LOT 7 HENDERSONVILLE, NC 28792 -ft. ft. 1
si
Phvsical Address.City,and Zip 21.REMARKS
HENDERSON 9593292962 +. n g58In� l"
County Parcel Identification No.(PIN) II'•1'tv5t'"`�c nVVR So-c(;Qn
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field.one lal/long is sufficient)
N W 6-7-2021
Signature ofCe ' ed Well ContracU Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this jbrm,I hereby cerdjy that the well(x)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 FlNo copy ofthis record has been provided to the we//owner.
l/this is a repair,fill out known well construction inlormation and explain the nature ol'the
repair under=21 rentark .section or on the back q/'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.
1•or i n lliple injection or non-water.supply we/ty ONLY with the same construction,you can
suhndt one jhnu. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 705 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
I-or nudtiple wells list al/depths//'di/Jercnt(example-3@200'and 2 n 100') construction to the following:
10.Static water level below top of casing: 160 (ff) Division of Water Resources,Information Processing Unit,
/heater/ere/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(gpm) 1/2 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS 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
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