GW1-2021-06532_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
c.
1.Well Contractor Information:
14.
KOIby Sawyers FROMATER ZONES TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft• f`
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-cased hells'FOR LINER ifa heable
FROM TO DIAMETER' THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 57 ft. 6.25 i #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:
21100102202 FROM ft TO ft DIAMETEW in.
THICKNESS MATERIAL
List all applicable ire//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 SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. f. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft' 20 ft. Bentonite Pumped
Nun-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL 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 necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness soil/rock type,grainsiu etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 57 ft. OVER BURDEN
8-16-2021 57 ft 145 ft GRANITE
4.Date Well(s)Completed: Well[D# ft. ft.
5a.Well Location: ft. ft.
Andrew Moss ft. ft.
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft.
111 Holland Lane Hendersonville, NC 28792 ft. ft. 7 2
Physical Address,City,and Zip 21.REMARKS
Henderson 9690408520 �t
processln
County Parcel Identification No.(PTN) pyVR gG:.
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if'well field,one]at/long is sufficient)
N W -xa 8-25-2021
Signature off a tified Well actor Date
6.Is(are)the well(s): 21permanent or ❑Temporary By signing this farm,I hereby certify that the well(s)teas(were)constructed in accordance
with 15A NCAC 02C.0/00 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofthis record has been provided to the well owner.
4 this is a repair,Jill out known well construction information and explain the nature oj'the
repair under:21 remarks.section or on the hack(if 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.
Pbr nudtiple injection or non-water supply hells ONLY with the same construction,you can
suhmit one jbrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 145 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
I,or nudtiple irells list all depths it different(example-3 a 200'and 2 n l00') construction t0 the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
/l hater level is ahore 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 24aabove, 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) 20 Method of test: RI
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 G W-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013