GW1-2021-00215_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 1'O DESCRIPTION
Well Contractor Name
4471-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a Gcable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 70 It 6.25 in. 1 #21 1 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
21100103896 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: tt. tt. in.
List all applicable well permits(i.e.County,State. Variance,Injection,etc.)
ft. fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. in.
ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
El Irrigation 0 ft. 20 rt. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. R.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquiter Storage and Recovery ❑Salinity Barrier ft. rt.
❑Aquifer Test ❑Stonnwatcr Drainage
rt. rt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiltrocktype,gnin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 70 rt OVERBURDEN
11-10-2021 70 ft 405 ft GRANITE
4.Date Well(s)Completed: Well ID#
,a.Well Location:
Visionary Renovations LLC
Facility/Owner Name Facility ID#(if applicable)
668 Pace Road Hendersonville, NC 28792 ft ft. zj
Physical Address,City,and Zip 21.REMARKS
Henderson 9680914030
County Parcel Identification No.(PIN)
Sb,Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W 11-18-2021
Signature of Certlfl Well Contractor I Date
6.Is(arc)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certifi,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 FlNo cop),gf1his record has been provided to the well owner.
If/his is a repair,till out known well con.siruction inforrna/ion and explain the nature of'the
repair under 421 remarks 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 nulliple injection or n(in-water,supph wells ONLY with the same construction,you can
511hind one Join. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 405 —(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths rfdillereut(example-3 cil200'and 2@100') construction to the following:
10.Static water level below top of casing: 50 (ft) Division of Water Resources,Information Processing Unit,
{Grater level is above 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 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
13a.Yield(gpm) 2 Method of test: RIG
24c.For Water Supply&Injection Wells:
Also submit one copy of this form 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
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013