GW1-2022-03943_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
Kolby Sawyers 14.WATER ZONES "
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased'wells)OR LiNER a 'Gcatdo)
FROM I TO I DIAMETER I THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 65 ft- 16.25 ' i #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed400 ',
21100124886 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt. in.
List all applicable"ell permits(i.e.County,State. Variance,injection,etc.) g fit in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERAAI,
in.
❑Agricultural ❑Municipal/Public
ft. fit. in.
❑Geotheral(Heating/Cooling Supply) ElResidential Water SuPP1Y(single)❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 fit. 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 fit. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. fit.
❑Experinmental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Ceothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gnin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft- 65 ft. OVER BURDEN
3-4-2022 65 ft- 345 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: fit. fit.
Big Oak Builders LLC
Facility/Owner Name Facility ID#(if applicable) ft. ft. - `
46 Kiwassa Lane Hendersonville, NC 28792 fit, rt.
Phvsical Address,City,and Zip 21.REMARKS
Henderson 0600358397 M11. 1i7
County Parcel Identification No.(PIN) li'a a si.wFi fuMll i'iJ a%ti:9UIV
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certific 'on:
(if well field,one]at/long is sufficient)
3-15-2022
N W
gnature of e t V
Well Contract Date
6.is(are)the well(s): ❑O Permanent or ❑Temporary Br signing this form,I hereby certi/B that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.1/100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E lNo copy ofthis record has been provided to the well owner.
//'this is a repair,fill out known live//construction information and explain the nature of the
repair under 421 remarks section or on the back of this.1brm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection urn nun-water.supply wells ONLY with the saute construction,you can
cud„nit an,fan„ SUBMITTAL INSTUCTIONS
9.'1otal well depth below land surface: 345 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple}cells list all depths iI dilkrent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 60 (ft) Division of Water Resources,Information Processing Unit,
If eater level is above easing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b. For Infection Wells ONLYv 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) 4 Method of test: RIG
24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13h.Disinfection type: PILLS Amount: 30 well construction to the county health department of the county where
constructed.
Foram GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 201'