GW1-2021-06536_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD For Internal Use ONLY:
,This form can be used for single or multiple wells
I.Well Contractor Information:
14.Kolby Sawyers FROMATERZOTONES
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 a licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 70 ft. 6.25 i" #21 1 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM
2.Well Construction Permit#: 21100107155 ft TO ft DIAMETER THICKNESS MATERIAL
List all applicable irell permits(i.e.County,State,Variance,Injection,etc.J
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
f. ft. in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 20 fr. Bentonite Pumped
Non-Water Supply Well:
rt. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery FROM❑Salinity Barrier ft. TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG:attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sire,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 70 ft. OVER BURDEN
9-28-2021 70 fr 365 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft. it.
5a.Well Location: ft. ft.
Mathew Jackson ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft, rt.
104 Fish Hawk Drive Hendersonville, NC 28792 ft. ft.
Physical Address.City.and Zip 21.REMARKS
Henderson 9556493647 ,eSSin9
County Parcel Identification No.(PIN) CgCi�O(�
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification: J
(ifwell field one]at/long is sufficient) /
N w 10-13-2021
Signature of Certifie ell ContractorIL3
Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby cerlt&that the u-ell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or FlNo copy ofthis record has been provided to the well owner.
If dli.s is a repair,fill oul known well construc•lion ailbrmalion and explain the nature oj'the
repair under 2/remarks sec lion or on the hack q/'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.
1-hr mubiple igiec•lion or non-waler supply wells ONLY with the same construction,you can
sunnia one 1brm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 365 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
I-or nwhiple we11.s list a//depl/r.s tfdt#j,renl(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
I/'waler level is abore casing use"I" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b. For Iniection Wells ONLY: In addition to sending die 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,iUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,nter,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: RI
24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 35 well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013