GW1-2021-06530_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolb Sawyers 14.WATER ZONESx
Y y FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. e.
NC Well Contractor Certification Number 15.;OUTER'CASING<for multi-cased wells)OR.LINER if a 'livable FROM TO DIAMETERi THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rr. 50 ft- 16.25 '" #21 PVC
Company Name 16.INNER CASING'OR TUBING(geothermal closed-loo
21100111829 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: fr. fr. in.
Li.ct ull applicable well permits(i.e.County,State,Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN �'A "
Water Supply Well: FROM TO DIAMETER JSLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. fr. in.
❑Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 fr. 20 ft- Bentonite Pumped
Non-Water Supply Well:
fr. fr.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recover}' ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20:DRILLING LOG'attac additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer R
TO DESCRIPTION color,hardness,soiltrack a rain sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 50 fr. OVER BURDEN
7-12-2021 205 ft GRANITE
4.Date Well(s)Completed: Well ID#-5a.Well Location: ft.
C Solesbee LLC ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Walt Drive HoneyCrisp Lot 2 Hendersonville MC 28792 ft. R. 2 U0
Ss�n
Physical Address,City,and Zip
21.REMARICS' � `0
Henderson 050918619 n pW
County Parcel identification No.(PIN)
.5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if'well field one]at/long is sufficient)N w /w� } -
8-25-2021
Signature ofC�ed Well CorQfor
Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this Dorm,I hereby certify that the well(s)was(here)constructed in accordance
with 15A 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 171No copy ofihi.s record has been provided to the we/l owner.
I/this is a repair,fill out known well construction in%rmation and explain the nature of the
repair under 2l remarks section or on the hack g1this 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.
Him multiple injection or non-water.supply wells ONLY with the same construction,you can
suhmit one form. SUBMITTAL INSTLICTIONS
9.Total well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hit-multiple wells list all depths i(difjerent(example-3@200'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,
I/'water lerel is abm•e caring 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
m 7 Method of test: RIG 24c.For Water Supply&Injection Wells:
13a.field(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 hedlth department of the county where
constructed.
c
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013