GW1-2021-00205_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
j14"WATER ZONES:
Kolby Mitchell Sawyers F .• :. '�.,.
ROM 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 ffa"'lieal)le
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rr• 80 16.25 i" 1 #21 PVC
Company Name 16 INNER CASING OR TUBING eothermal closed400
20100122425 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. it. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 447.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE 'THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ElResidential Water SuPPIY(single) in.
❑Industrial/Commercial ❑Residential Water Supply(shared) %J&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 rt. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAA'D/GRAVEL PACK if apptic0le
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwatcr Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING'liOG attach additiooa'1'sheetsif necessary)
� .:.:' °'•=
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION colon hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 80 ft. OVER BURDEN
9-30-2021 80 ft- 185 ft- GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft.
Boyd Hyder
Facility/Owner Name Facility lD#(ifapplicable) ft. ft. LJLC 13 20
21
71 Clark Rd. ft.
Physical Address,City,and Zip
21.REMARKS"-,''
Hendersonville 9690769705
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one]at/long is sufficient)
N W CXA
11/29/2021
Signature of Certifi Well Contractor Date
6.Is(are)the well(s): @Permanent or ❑Temporary Br signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ZlNo copy of this record has been provided to the well owner.
lfthis is a repair,full out known well construction information and explain the nature ojthe
repair under#21 remarks section or on the back ofthis 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.
For multiple injection or non-water supply wells ONLY with the same construction,you ran
submit one form. p C SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiJferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 tut) Division of Water Resources,Information Processing Unit,
/f water level is above 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,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test:
20 RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this foim within 30 days of completion of
13b.Disinfection type: PILLS Amount: 35 well construction to the county health department of the county where
constructed. f
Forth GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013