GW1--06083_Well Construction - GW1_20230921

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers `
R'e1lContmctorName
FROM TO DESCRIPTION
ft. ft. f
4471-A
ft. ft.
NC Well Contractor Certification Number ay;t Vil 12:ei j YOfir iiiultl,ca'scd i iitl's):t Ritil Fit'fai(i Ikablelgr�.4'
CLYDE SAWYERS&SON WELL& PUMP INC FROM TO DIAMETER' THICKNESS MATERIAL.
+1 it 42 ft• 6.25 I in" #21 PVC
Company Name
OSS-2023-0603 low:iIv.Ko Gagisc tilil:Ttit;11iGF(u`lte;'uritclosoii=ib q)' 4.. To.
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable lye!l construction permits(i.e.UIC,County,State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE _ THICKNESS MATERIAL
ill Agricultural Municipal/Public ft. ft. in..
+Geothermal(Heating/Cooling Supply) E:3Residential Water Supply(single) ft. ft. in:
'Industrial/Commercial OResidential Water Supply(shared) fit soG Ito Ua' n,. , ,, M
'irrigation FROM TO MATERIAL EM PLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. Bentonite! Pumped
111 I Monitoring Recovery ft. ft. I Cap Top with Bentomite chips
Injection Well:
ft. ft. ,
'Aquifer Recharge ®Groundwater Remediation 1 AMY/G VERPAGK'(fau"pliOifilrl "?u �ge :
Ali Aquifer Storage and Recovery E3SalinityBarrier FROM TO MATERIAL _ EMPLACEMENT METHOD
Ii Aquifer Test 0StonnwaterDrainage ft. ft.
1!ExperimentalTechnology 0SubsidenceControl ft. ft.
)NiGeothermal(Closed Loop) ®Tracer BObkIRRY1Nallt1G(auaciiaililitiW�sleit"siFSieresshj} ,,,,, '
FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
a.Geothermal(Heating/Cooling Return) ®Other(explain under#21 Remarks)
a ft, 42 ft• OVER BURDEN
4.Date Well(s)Completed:$-7-2023 Well ID# 42 ft. 205 ft' GRANITE
a
Sa.Well Location: ft. ft. I 't,a..••C f ET- \f -1 1
RYAN HENKLE ft. ft. (Cp `
Facility/Owner Name Facility ID#(if applicable) ft. ft. J E f r ����
SIMPLY GRATEFUL DRIVE HENDERSONVILLE, NC 28792
ft. ft. U
Physical Address,City,and Zip ft. ft. [><v(aL�ia
HENDERSON 0621111904 fSs�i°.,,`wiA'R ' -"Wx, ' ,
County Parcel Identification No.(PiN) this well was self certified
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: '
1.
N W
8-8-2023
6.ls(are)the well(s) Permanent or Temporary Sigma a of et ed onhador Date
X
By signing tlr Orin,1 hereby cerrifj'Nite the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or x3No with 15A NCAC 02C.0/00 or 15A NCAC 02C.020(1 Well Construction Standards and that a
If this is a repair.•fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#2I remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page'to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS I
9.Total well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ifd(fferent(example-3@,200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resoulrces,information Processing Unit,
I/'water level is above easing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
ROTARY above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following: I
(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
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13a.Yield(gpm) 7 Method of test: RIG 24c.For Water Supply&Iniection:Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: PILLS Amount: 35 completion of well construction to: the county health department of the county
where constructed.
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Form OW-i North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-2016