GW1-2021-00204_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
14.WATER ZONES
Kolby Mitchell Sawyers FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased:wells)OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 16g ft• 16.25 in. #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
21100111601 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County.State, Variance,Injection,etc.)
f[. ft. in.
3.Well Use(check well use): 17.SCREEN i-
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
ft. ft. In
❑Geothermal(Heating/Cooling Supply) El Residential Water SuPPIY(single)
❑Ind u stria l/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrieation 0 ft. 20 ft• Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer"rest ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiltrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 68 ft. OVER BURDEN
9-13-2021 68 I'L 305 ft. GRANITE
4.Date Well(s)Completed: Well ID#
tt. tt.
5a.Well Location:
r
LINDA&ZEB OWENBY ft. tt.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. D
EC
38 CARLISLE DRIVE HENDERSONVILLE, NC 28792
ft. ft.
Phvsical Address,City,and Zip 21.REMARKS
Hendersonville 0509180790
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well Field,one tat/long is sufficient)
N w
11/29/2021
Signature of Certifi Well Contractor I Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary Br signing this form,I hereby certijB 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 E3No cap)-ofthis record has been provided to the well owner.
lfthis is a repair,fill out known well construction information and explain the nature gj(he
repair under#21 reorcrrks section or on the back of 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.
For multiple injection or non-water supplv wells ONLY with the same construction,you can
suhmil one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i/'different(example-3@200'and 2G100') construction to the following:
10.Static water level below top of casing:
40 Division of Water Resources,Information Processing Unit,
(ft.)
If matey level is above casing,use'+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection 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,rutarv..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 m 5 Method of test: RIG 24c.For Water Supply&Injection Wells:
(gP ) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 30 well construction to the county h°ealth department of the county where
constructed.
Form 6W-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013