GW1--01164_Well Construction - GW1_20240219

Print Form ,
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers I4 vAtrER,zonsr ; = gRamu .. n4wAammv : ,,
R'ellContractor Name FROM TO DESCRIPTION
ft. ft.
4471-A
ft. ft.
NC Well Contractor Certification Number IIIIKb)TER'G;AMNG(farmtiiti.cesei iiiiii)•URLINEIt(ii`uptteable)Mllatn. il'e.
CLYDE SAWYERS&SON WELL&PUMP INC FROM TO MAMEtER THICKNESS M.ATERIAI.
+1 ft• 60 ft' 6.25 in #21 PVC
Company Name
22100111633 s)Ic1NNElR:CASlNC OR ELBtNC(catlserntal c►osed-Ioo tU t .4..
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): et. ft. in.
Water Supply Well: Fu:1 ThSCREENT/v cc gs I. _ * : R . Yh zi;;'"..•
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural �Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) ['Residential Water Supply(single) et, ft. in.
industrial/Commercial Residential Water Supply(shared) Ig GROUT I ,�, 4 ems 5
irrigation FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: UU
0 ft' 20 ft' Bentonite Pumped
Monitoring Recovery ft. ft. Cap Top with Bentomite chips
Injection Well:
ft. ft.Aquifer Recharge 0 Groundwater Remediation
19 SA'NEI/GRAVL`T.)'PACIC(if applieill le)v'�rz�,.`.;'? ate' i`,°:' _
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test fStolntwaterDrainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
(Geothermal(Closed Loop) EjTracer '311 DRILLINGFT.t)G.(auach`'addrtiona(sheetilf necessary)'n .. . :N
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Retum) Other(explain under#2I Remarks)
0 ft. 60 ft• OVER BURDEN
4.Date Well(s)Completed: 1-4-2024 Well iD# 60 ft. 275 ft. GRANITE
ft. ft.
5a.Well Location: 1 I pp :Ly 3.. \.t . L
Calvin Davis fL ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. rEli 1 9 [OZ4
425 Lindsey Loop Road Hendersonville, NC 28792 fL ft. .
t `cr r�r^rl?rf,.47 n.2 li-Kic
Physical Address,City,and Zip ft. ft. DWOI3 -
Henderson 9673784322 1l21tiREMARKS; s `x . W-4 . • k4, V r
County Parcel identification No.(PiN) Well was self nArfifiM
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: •
N A' 1-5-2024
6.Is(are)the well(s)OIX Permanent or Temporary Sigma a of er ed onh rdor Date
By signing rh Orin,1 hereby certify that rite wells/was(were)constructed in accordance
7.Is this a repair to an existing well: 0 Yes or 0No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair.ill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the hack of this form.
23.Site diagram or additional well details:
I.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 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: 275 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2 a/00') construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,information Processing Unit,
1f water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection 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.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(gpin) 15 Method of test: RIG 24c.For Water Supply&Injection 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: 25 . completion of well construction to the county health department of the county
' where constructed. !
Form C W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016