GW1-2022-02907_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Kolby Mitchell Sawyers FR WATER ZONES
FROM '1'O DESCRIPTION
Well Contractor Name ft. ft.
4471-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased Hells)OR LINER ifa 6cable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 f` 66 f` 6.25 j ;" #21 PVC
Company Name 16.INNER CASING OR TUBING `eothermal closed-lob
21100114332 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: tt. 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 FRont To DIAMETER SLOT SIZE THICKNESS MATERIAI.
tt. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) El Residential Water SuPP1Y(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 fi• 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
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)J 0 ft• 66 f`• OVER BURDEN
2-3-2022 66 f` 225 f` GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
C Solesbee LLC --
Facility/Owner Name Facility ID#(if applicable) FEB
ft. ft. _
Honeycrisp lot 7 Hendersonville, NC 28792 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Henderson 0509188353
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
V_vl� ) cia T-4 02/15/2022
N W
Signature of Cerlifi Well Contractor Date
6.Is(are)the well(s): ❑✓Permanent or ❑Temporary By signing this for,n,I hereby certiift that the well(s)was(were)constructed in accordance
With 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Consan,ction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo cap)-gf1his record has been provided to the well owner.
(('this is a repair,fill out known well construction infbnnation and explain the nature of the
repair mtder#21 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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supplr wells ONLY with the sane construction.You can
smbmil one form. SUBMITTAL INSTUCTIONS
9.'total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths rf d{jjerent(example-3@200'and 2G100') construction to the following:
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
If stater 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) 5 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: 20 well construction to the county health department of the countywhere
constructed.
V
Foam CiW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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