GW1-2021-06535_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
14.WATERZONES-
Kolby Sawyers ('•
FROM TO DESCRIPTION
Well Contractor Name
4471-A
NC Well Contractor Certification Number 15.OUTER.CASING.for multi-caLTd, lls OR.L[NER.if a licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 98 ft- 16.25 i" #21 PVC
Company Name 16.•INNER CASING OR TUBING(geothermal closed-loop)
21100109588 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well pernits(i.e.County,Stale,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. tt.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fr. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
[]Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sin,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 tr. 98 ft. OVER BURDEN
10-1-2021 98 it• 145 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
Kenneth Corn ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft ft
Rockwood Drive Hendersonville, NC 28792 ft. ft.
ni9
Phvsical Address,Citv,and Zip 21.REMARKS
onn
Henderson 9680867516 pyVR eGi.
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient)
N � n�� 10-13-2021
Signature-of Certified ell Contractor Date
6.Is(are)the svell(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the we/1(s)was(were)constructed in accordance
with 15A NCAC 0X7.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy ofthis record has been provided to the we//owner.
Ifihis is a repair,fill out known well construction information and explain the nature q/lhe
repair under':21 remarks section or on the back(if this farm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
I-'or multiple injection or non-waler supply wells ONLY with the sane construction,you can
.submit one torn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 145 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
hbr multiple weU.s fist all depths il di//erenl(example-3 a 200'and 2@100') construction to the following:
10.Static water level below top of casing: 40 Division of Water Resources,Information Processing Unit,
if itater/erel is ahore casing,use",." 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
ROTARY 24a above, 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,jUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
m 15 Method of test: RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gp ) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount 20 well construction to the county health department of the county where
constructed.
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Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013