GW1--03522_Well Construction - GW1_20240612

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers 14.WAT'Elt ZONES 5v.: .,
FROAI TO DESCRIPTION
Well Contractor Name ---------
ft. ft.
4471-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap Iicable)
CLYDE SAWYERS & SON WELL & PUMP INC mom To mssic1'N:R I'HICkN1SS MAIERIAl,
+1 ft. 75 ft. 6.25 in. #21 PVC
Company Name
O S S-202 3-1155 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMEFER Tun k\-NS MAIERIAI,
List all applicable well construction permits li.e.(TIC.Counm,State,Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft' ft. in.
Water Supply Well: 17.SCREEN ` ;"
FROM ro DI%ME.TFR _SI III SIZE TttIC KYFSS MATERI II.
Agricultural ElIttunicipal/Public ft. ft. 1 in.
Geothermal(Heating/Cooling supply) Lip esidential Water Supply(single) ft. ft. in.
❑IIndustrial/Commercial Eipe,idential Water Supply(shared) 18 GROUT
',Irrigation FRON1 10 NI ATF141 1 1 NI PI ACFMF\T MI rHOD&Aswu\r
Non-Water Supply Well: o ft. 20 1't. Bentonite Pumped
0Moni tor ing Recovery ft. ft. Cap Top with Bentomite chips
Injection Well:
—
ft. ft.
0Aquit'cr Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0Salinity Bonier FROM To N1,1l'ERI.NI._ ESIPE.0 EME\T MF;IHOD
Aquifer Test OStonnwater Drainage ft. ft.
0 Experimental Technology 0 Subsidence Control ft. ft.
DGeothermal(Closed Loop) DIracer 20.DRILLING LOG(attach additional'sheets if necessary)
()Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(color.bantam.soil/rock type,groin size,etc.)
0 ft. 75 ft. OVER BURDEN
4.Date Well(s)Completed:4-2-2024 Well I D# 75 H 205 ft• GRANITE • :• /
Sa.Well Location:
ft. ft. I�N+- l..: i/ E�„f
CHERYL OWENS ft. ft. JUN 1 2 2024
Facility O w tamer Facility ID#(if applicable) ft. ft.
4 PONDEROSA DRIVE HENDERSONVILLE NC 28792 ft. ft. Itgorg-A l"`a ;#•r;,� :-r!t17t�
' 1W is lC•ti
Physical Address,City,and Zip ft. ft.
HENDERSON 9673364515 21.REMARKS
County Parcel Identification No.IPiN) THIS WEI L WAS SEI F-CFRTIFIFD
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latttong is sufficient) 22.Certification:
N A 4-10-2024
6.Is(are)the well(s)OX Permanent or ®Temporary Sig a of lei ed onanctor Date
By signing th Orim,1 hereby cern"),that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or xONo with/5A,VCAC 112C,1)100 or/5A MAC 02C.'.0201 Well Construction Standards and that a
If this is a repair.fill out known well construction information and explain the nature ofthe copy o/this record has been provided to the yell owner.
repair under 421 remarks section or on the hack of this j n-nt.
23.Site diagram or additional well details:
3.For Ceoprobe/DPT or Closed-Loop Geothermal Wells having the Sams 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: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdiJ)creru(example-3(l/200'and'(CIOU') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,information Processing Unit,
//water lord 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.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) 10 Method of test: RIG 24c.For Water Supply&Injection Wells: In addition to sending the form to
PILLS the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 20 completion of well construction to the county health department of the county
where constructed.
Form COW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016