GW1-2021-06537_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolb/ Sawyers 14.WATERZONES t t
FROM TO DESCRIPTION
Well Contractor Name ft. f[.
4471-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased ells)OR LINER ifapplicable)
,,.
FROM TO DIAMETER' THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 72 ft. 6.25 i" #21 PVC
Companv Name 16.INNER CASING OR TUBING(geothermal closed-loop)
21100114331 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
list all applicable well permits(i.e.Coumy,State,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. i"• '
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 fr. 20 ft- Bentonite Pumped
Nun-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
'
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. 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 Retum) ❑Other(explain under#21 Remarks) 0 ft. 72 ft. OVER BURDEN
9-29-2021 72 ft- 145 1" GRANITE
4.Date Well(s)Completed: Well iD#
ft ft.
Sa.Well Location:
Darron Case
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
868 Townsend Road Hendersonville, NC 28792 ft. rt.
Phvsical Address,Citv,and Zip 21.REMARKS
Henderson 9681623722 ssing Jn'
County Parcel Identification No.(PIN) ��.� NR t CJ`eC,1lOO
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(it-well field.one lat/long is sufficient)
N Wn 10-12-2021
Signature ofCerti Well Contrac o Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By,signing this form,I hereby certify that the we/l(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy oJ'thi.s record has been provided to the u,e//owner.
ll this is a repair,Jill out known well construction information and evplain the nature of the
repair under=2l remarks section or on the back q/this form. 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.
kor nndliple injection or non-water supply wells ONLY with the same construction,you can
suhinn one lornt. 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
hior nndliple wells list all depths it difkrenl(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
l/baler 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 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.field(gpm)
15 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13h.Disinfection type: PILLS Amount: 2O well construction to the county health department of the county where
constructed.
i
Form G W-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 201-33