GW1-2022-02905_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells s ti'z=. I p D
r.,- e,a9 T�Fr
1.Well Contractor Information: IL
Kolby Mitchell Sawyers 14.
FROM ER ZONES I' t. FEB RO\I 'I'O Di:SCRII'TION `/
Well Contractor Name ft. ft. I `
4471-A ft. ft. i D
GoG
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. 1157 ft 6.25 #21 1 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
21100120580 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: R. ft. i in.
List cdl applicable well permits(i.e.County,State, variance,htjection,etc.)
ft. fl. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIn1,
❑Agricultural ❑Municipal/Public
i. f. in.
❑Geothermal(Heating/Cooling Supply) ]Residendal Water SuPPIY(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft. 20 f" Benton ite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer TCst ❑Stormwater Drainage
ft. ft.
❑Experinmcntal Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/mck type.grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 157 ft. OVER BURDEN
1-26-2022 157 ft 285 ft GRANITE
4.Date Well(s)Completed: Well ID#
ft. rt.
5a.Well Location: ft. ft.
Charles Capps
Facility/Owner Name Facility ID#(if applicable)
Pleasant Meadow Lane Minor Sub Lot 3 Hendersonville,NC 28792
Physical Address,City,and Zip 21.REMARKS
Hendersonville 9589850893
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if v,ell field,one lat/lone is sufficient)
N W 1-28-2022
Signature ofCerfifiJirwell Contractor Date
6.Is(are)the well(s): RPermanent or ❑Temporary Br signing this form,1 hereby cert!bi 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 ONo copy 4f1his record has been provided to the well owner.
/(this is cr repair,fill out known well construction in/-nation and eerplain the nature of the
repair under#21 remarks section or on the hack o/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 nudtiple injection or non-water supp/r wells ONLY with the scone construction,you can
submit onefbrtn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 285 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For mitkiple wells list all depths i/'d{'/jcrent(example-3@200'and 2L100') construction to the following:
10.Static water level below top of casing: 40 (ft) Division of Water Resources,Information Processing Unit,
Il hater 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 ilthis 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) 5 Method of test: RIG
24c.For Water Supply&Injection Wells:
Also submit one copy of this forim within 30 days ofcompletion of
13h.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