GW1-2021-01527_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD bar wI YwWernal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: LV�a� V 2 x
KOLBY MITCHELL SAWYERS ���. , �TO DESCRIRfP.. TION ----- -
Well Contractor Name in►ormation Proms
4471-A 0\NR SeCtIcin
ft. ft.
NC Well Contractor Certification Number ,:bUl #tl>liSt1+C:.ton-::multi ca melts (3it><Lil!tli f itcabte"s-:
FROAT TO DIAMF,TF.R I THICKNESS I MATERIAL.
CLYDE SAWYERS AND SON WELL +1 ft- 139 ft. 6.25 #21 PVC
Company Name 3M1K.1�CAfNG.UR.'.Ft7pll�.fa. 4ofhrx:Al:alst~Ios¢[1-1Qo:� ap�,.>i i
19100114383 FROM DIAMETER I THICKNESS LNIATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): N _
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal (Heating/Cooling Supply) OResidential Water SuPPIY(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 3fl-(Itt)0T
FROM TO �MATF.RLAL m EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 et• 20 ft. BENTONITE PUMPED
Non-Water Supply Well:
ft. fL
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO
ft. ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft, fr.
❑Experimental Technology ❑Subsidence Control Dtitlf �eti adrlifiapal shcefsiaec�ssa'x
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rwk ry a gnin size,etc.)
❑Geothermal (Heating/Cooling; Return ❑Other(explain under#21 Remarks) 0 ft• 39 ff• OVER BURDEN
ft. fr.
4.Date Well(s)Completed: 02/03/2021 Well ID# 39 ft• 345 ff• GRANITE
5a.Well Location:
ft. ft.
Aggressive Properties&Development LLC
Facility/Owner Name Facility ID#(if applicable)
ft, ft.
318 Souther Rd., Hendersonville ft. ft.
Physical Address,City,and Zip
---------------
Henderson 9672292004
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
N Wri. M An 02-03-2021
wSw. -IfiedMil ContKty
Date
to
6.is(are)the well(s): OPermanent or l7Temporary
rty silming this Jin-m.1 herehv ct the well(N)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 nr 1 sA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: El Yes or ❑No copy ojthis record has been provided to the well oxwer.
If this is a repair,fill out knuwn-ell construction informatiun and explain the nature of the
repair under VI remark-section or on the back ojthis form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 345 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3(V00'and 2(a'1001 construction to the following:
10.Static water level below top of casing: 30 (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 Iniection Wells ONLY: In addition to sending the form to the address in
ROTARY AIR 24aabove, 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) 3 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type- PILLS Amount: 30 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013