GW1-2021-06531_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:
K Sawyers 14.`WATER'ZONES
olb
Y Saw y FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number 15.OUTER:CASING for multi-cased wells OR LINER'`if a livable -
FROM TO DIAMETER' THICKNESS1 MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. 58 rt• 16.25 1 #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
20100104292 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
Li.ci all applicable well permits(t.e.Counl,Stale,Variance,Injection,etc.)
fr. 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
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT-
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 rr. 20 It- 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. fr.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑L-xperimental 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#21 Remarks) 0 ft. 58 a. OVER BURDEN
8-23-2021 58 ft. 105 rt. GRANITE
4.Date Well(s)Completed: Well iD# ft. ft.
5a.Well Location: ft. ft.
Aggressive Properties& Dev ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
lip
857 Townsend Road Special Sub lot 3 Hendersonville, NC 28792 rt. tr.
Physical Address,City,and Zip 21.REMARKS
Henderson 9681528601 �,IOGes.
County Parcel Identification No.(PIN) �(1 t s D�R
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if'well field.one lat/long is sufficient)
N W 8-26-2021
Signature 017Ceffed 7.11Mnu r Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,1 hereby certify that the well(s)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 ElNo copy ofihis record has been provided to the wel/owner
ll this is a repair.Jill oul known well construction ignrmalion and explain the nature of the
repair larder'2/remarks.section or on the hack 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.
I,w-nudiiple injection or non-water supply we//.r ONLY with the suite construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 105 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
I-or noiltiple wells list all depths ijdilferent(example-3w00'and 2 a 100') construction t0 the following:
10.Static water level below top of casing: 20 Division of Water Resources,Information Processing Unit,
//waler level is above casing,use-t" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b. For Infection 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
m 13a.field
(gp ) 50 Method of test: RIG 24c.For Water Supply&lnjection�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-I North Carolina Department cf Environment and Natural Resources-Division of Water Resources Revised August 2013