GW1-2022-03953_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD For Internal Use ONLY:
Thin firm can he used for single or multiple wells
I.Well Contractor information:
Kolby Mitchell Sawyers FROwATERZONES` DESCRIPTION
Well Contractor Name
ft. ft.
4471-A ft. tit.
NC Well Contractor Certification Number i5.OUTER CASING(for multi-eased wells)OR LINER if a 6cable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt• 1118 ft- 6.25 #21 1 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
21100121694 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Caaniv..State. Variance,hyectiott,etc.) ft. ft. in.
3.Well Use(check well use): i7.SCREEN
Water Supply Well: FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
ft. ft. in:
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft• in.
b PP Y) PP Y( g )
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 F" 20 ft- Bentonite Pumped
Non-Water Supply Well:
rt. rt.
❑NIon itori ng ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. tit.
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiltrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) 0 rt• 118 ft. OVER BURDEN
3-2-2022 118 f`• 585 fr• GRANITE
4.Date Well(s)Completed: Well iD#
ft. rt.
5a.Well Location: ft. ft.
CMH Homes Inc
Facility/Owner Name Facility ID#(if applicable)
72 Neely Drive Hendersonville, NC 28792 APR 2 202?
Phvsical Address,City,and Zip 21.REMARKS
Henderson 0601225681 r. t::NR>,
County Parcel Identification No.(PIN) t vvt, Cctx+I t` y
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient) KIA ) 3-14-2022
N W
Signature of Certift Well Contractor Date
6.is(are)the weli(s): ❑O Permanent or ❑Temporary Br signing this form,1 hereby certify that the tvell(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 E]No copy qf1hi,s record has been provided to'the well owner.
I/thk is a repair,fill out known well construction inlbrntation and explain the nature o.1 the
repair under N21 rentarks section or at the back ojthis 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.
Fur nudtiple injection or non-water supply veils ONLY with the sane construction,you can
suhwil one,lornt. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 585 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths il*Qlcrent(example-3@200'and 2 ct 100') construction to the following:
10.Static water level below top of casing: 120 (ft•) Division of Water Resources,Information Processing Unit,
//,,atcr hmel 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) Method of test: RIG
24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: PILLS Amount: 35 well construction to the county health department of the countywhere
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013