GW1-2021-00207_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:
Kolby Mitchell Sawyers FROMATERZONES - DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NCWeIIContractorCertificationNumber -15.OUTERCASING for:multi-casedWells)ORLINER`ifa-p able
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft' 63 ft- 6.25 1" 1 #21 PVC
Company Name 46.INNER'CASING OR TUBING''°eothermil closed-too"`.
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 21 1 001 1 201 O ft. ft. in.
List all applicable well 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 MATERAAI.
ft. ft. is
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft tt. m
c 18.'GROUT ,
❑industrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑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
❑Aquifer Test ❑Stormwater Drainage
rr. rt.
❑Experimental Technology ❑Subsidence Control
20.:DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) []Tracer FROM I TO DESCRIPTION color,hardness,soil/rock type,gnin sae,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 63 f1• OVER BURDEN
11-4-2021 63 ft 505 it GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location:
CARL SOLESBEE
Facility/Owner Name Facility iD#(ifapplicable) rt. ft.
Walt Dr/ Honeycrisp lot 17 Hendersonville, NC 28792 ft. I ft.
Physical Address,City,and Zip 21.REMARKS`':
Hendersonville 0509183706
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)
N WV__d 11/18/2021
Signature of Certifi Well Contractor Dale
6.Is(are)the well(s): 2Permanent 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 KlNo copy ofthis record has been provided to the well owner.
If this is a repair,Jill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back ofthisform. 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 supply wells ONLY with the same construction,von can
SUBMITTAL INSTUCTIONS
submit one form.
9.Total well depth below land surface: 505 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple hells list all depths ifdifjerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of easing: 80 (ft.) Division of Water Resources,Information Processing Unit,
if truer level is above casing,use'•+•' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection 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 13a.Yield
(gp ) 1'5 Method of test: RIG 24c.For Water Supply&In,iection Wells:
Also submit one copy of this foim within 30 days of completion of
13b.Disinfection type. PILLS Amount: 35 well construction to the county health department of the county where
constructed. i
Foram 6W-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013