GW1--06099_Well Construction - GW1_20230921

•
R FrilFrrli
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers ..4:AVA't'ER:ZCINEB r.,'" ` ,,' . OR
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number
4Ct51"t'[LReCi#vGr{for"tia[N easedtvells��`t1RzLWEir(ifiir fca"bte}�� '
CLYDE SAWYERS &SON WELL&PUMP INC FROM TO DIA al II PER"PH ICENFSS MATERIAL
Company Name +1 ft• 78 ft. 6.25 in" #21 PVC
s -- „.
055-2023-0696 cAstN OHADI lNOVcli a While de,;:lobe _.
x�1`6.z1#Vil`ER
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. , in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: (!7 5 IMB IOWi xA yA #.`
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
j�1Agricultural ®Municipal/Public ft. ft. in.,
l Geothermal(Heating/Cooling Supply) E2 Residential Water Supply(single) ft. ft. in.
a1Industrial/Commercial OResidential Water Supply(shared) 18:GRt)11T
!Irrigation FROM 'r0 [MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft• 20 ft• Bentonite' Pumped
II i Monitoring nRecovery ft. ft. Cap Top with Bentomite chips
Injection Well:
ft. ft. i
II I Aquifer Recharge ()Groundwater Remediation
S9ISAMI/GBAVELW CK'(it?np►ilt at le pralm '
iAquifer Storage and Recovery ®salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
II I Aquifer Test 0 Stonnwater Drainage ft. ft.
Experimental Technology []Subsidence Control ft. ft. .
x. - .. ,�.
*Geothermal(Closed Loop) Tracer �20�DRIlUTN`G�IOG(�ttiacti?:aJdr�onalihei~ts'rfne �x�;ce'ssary') `����
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) EjOther(explain under#21 Remarks)
0 ft• 78 ft• OVER BURDEN
4.Date Well(s)Completed:5-30-2023 Well ID# 78 ft. 805 ft' GRANITE
5a.Well Location: ft. ft. I �' ',f^' 7 i ( y-)
Patricia Tipton . ft. ft. � -� '''
Facility/Owner Name Facility ID#(if applicable) ft. ft. S E P 2 2013
504 Grand Oaks Drive Hendersonville, NC 28792 ft. ft.
Physical Address,City,and Zip ft. ft. D COOG
Henderson 0613068367 zt REMARKS - `,r . ,, `' -
County Parcel identification No.(PiN) V!(ell was self certified
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certification:
N w 6-15-2023
6.ls(are)the well(s) Permanent or Temporary Signa e of,er ed antractor Date
By signing Ch or,,,,1 hereby certifj'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or x3No with 15A NCAC 02C.0/00 or 15A NCAC 02C.0200 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#2l remarks section or cm the back of this firm, I
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the sane You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 805 (ft•) 24a. For All Wells: Submit this. form within 30 days of completion of well
For multiple wells list all depths ifd/ferenr(example-3@200'and 2@.100') construction to the following: I
10.Static water level below top of casing: 160 (ft.) Division of Water Resources,information Processing Unit,
If water level is above casing,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: 1
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service denier,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 Method of test: RIG 24c.For Water Supply&Injectilon1 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.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016