GW1-2021-03735_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
K 14.VATERZONES
olby Sawyers
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
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NC WzII Contractor Certification Number 15.`OUTER CASING formulti-eased wells TO DINER ifa`"licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 fl• 195 16.25 I i" #21 PVC
Company Name 16.'INNER CASING OR TUBING eothermal closed-loop)`
2.Well Construction Permit#: 19120119048 FROM ft. TO ft. DIAMETER to THICKNESS MATERIAL
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 SLOTSIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPIY(single) ft. f. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.'_GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK ifa licable
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 necessa
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION(color,hardness,soil/rock type,grain sin,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 f`• 95 f`• OVER BURDEN
7-19-2021 95 f`• 165 1" GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
Terry Nelson
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. y,� '•'
514 Nelson Valley Road Hendersonville, NC 28792 ft. ft.
Phvsical Address,City.and Zip 21.REMARKS
Henderson 9557963219 r�,.r.r�::s,I1
Aen:. ••JVwu
County Parcel identification No.(PIN) r^��„''?` ,��•� ^��• t
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification: y
(ifwell field one fat/long is sufficient)
N N - e 7-30-2021
Si ature ofCeqoed Well Conn Date
6.Is(are)the vvell(S): ©Permanent or ❑Temporary By signing this form,1 hereby certify that thewell(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or FINo copy ofthis record has been provided to the well owner.
l f this is a repair,Jill out known well construction information and explain the nature of the
repair under-'21 remarks.section or on the back q/7hts Jorm. 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 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: 165 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hbr multiple wells list all depths tif'dii#erent(example-3 n 00'and 2 a 100') construction to the following:
10.Static water level below top of casing: 50 (ft•) Division of Water Resources,Information Processing Unit,
water 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(gpm) 8 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: 20 well construction to the county health'department of the county where
constructed.
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Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013