GW1-2021-03737_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
KolbSawyers 14.WATER ZONES
Y y FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a lieable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 60 ft. 6.25 fin. #21 PVC
Company Name 16.INNER CASING OR TUBING eofhermal closed-loop)
21100109684 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permil.s(i.e.Counly,3iaie,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
f. it. in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water SuPPIY(single)❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
El Irrigation 0 rt. 20 ft- Bentonite Pumped
Nun-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa lieable
❑Aquifer Storage and Recovery ❑ FROM TO Salinity Barrier ft. ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
r20.DRILLING LOG attach additional sheets if nice ssa
❑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 rt. 60 ft. OVERBURDEN
7-16-2021 60 ft• 185 ft• GRANITE
4.Date Well(s)Completed: Well ID# tt. fi.
5a.Well Location: ft. ft.
Bi Oak Builders LLC
9
Facility/Owner Name Facility ID#(ifapplicable) -
ft. ft.
Kiwassa Lane Special Subdivision Lot 1 Hendersonville, NC 28792 ft. ft. (? F4 All
� J
Physical Address,City.and Zip 21.REMARKS
Henderson 0600358261
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
w N n0 7-28-2021
Signature ofCert i d Well Co for Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form, I hereby certif�that the well(s)was(were)consimc•led in accordance
with I5A NCAC 01C.0100 or I.iA NCAC 102C.0200 Well Construction Slandards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ojthis record has been provided to the well owner.
if this is a repair,,/ill out known well construction information and explain the nature of the
repair under 21 remarks.section or on the back gjrhi.s.fbrin. 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 nndliple injection or non-water.supply wells ONLY with the same construction.you can
submit one.lorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 185 24a. For All Wells: Submit this form within 30 days of completion of well
l-*or multiple wells/is/all depths ifdiifPrent(example-3 rt 200'and 2@100') construction to the following:
10.Static water level below top of casing: 50 (ft.) Division of Water Resources,information Processing Unit,
4%Toler level is above co.sing,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.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.field(gpm) 7 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.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013