GW1-2022-07722_Well Construction - GW1_20220819

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
KOlby Mitchell Sawyers 14.WATER ZONES FROM TO DESCRIP P
TION
Well Contractor Name
ft. ft.
4471-A ft. ft. l
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased v e0s)OR LINER(if a eable
FROM TO DIAMETER 6
THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 fc. 176 ft' 16.25 in. #21 PVC
Company Name 16.❑YNER CASING OR TUBING eothermal closed400`
21120124490 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Counq,,State, Variance.Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER' SLOT SIZE. THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) E(Residential Water Supply ft. ft. in.
d PP Y) PP Y
[ Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft' 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licible
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aqui1•er Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
rc. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gnin size,etc.
❑Geothenmal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) 0 ft. 176 ft. OVER BURDEN
6-27-2022 176 fc• 385 ft.
4.Date Well(s)Completed: Well iD# .�
ft. rt. y
5a.Well Location:
Richard Pauwels ft. ft. -
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. x �Y �-�^ 2:,.r;,�Uri!
N Ridge Rd Special Sub lot 2 Hendersonville, NC
Phvsical Address,City,and Zip 21.REMARKS
Henderson 28792 0600171789
County Parcel Identification No.(PM)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification-
(if well field,one tat/long is sufficient)
N 6-28-2022
Signature of Certifh Well Contractor I Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary Br signing this form,I hereb'v certily 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 WJNo copy gfthis record has been provided to the well owner.
//'this is a repair,fill out known well construction information and arplain the nature of the
repair under 921 remarks section or on the back gfthis,jorm. 23.Site diagram or additional well details:
Ycu 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 multiple injection or non-water supph•wells ONLY with the same construction,sou can
.submit one lbrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 385 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi(lerent(example-3@200'and 2@100') construction to the following: -
10.Static water level below top of casing: 50 (ft,) Division of Water Resources,Information Processing Unit,
/f water level is above casing,itse"+ 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) `�
C 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.
Fora GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013