GW1-2021-00208_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:
KOlby Mitchell Sawyers FR WATER ZONES
FROM TO DESCRIPTION
Well Conti actor Name
ft. ft.
4471-A ft. ft.
i
NC Well Contractor Certification Number 15.OUTER CASING for multi-easedtivells OR LINER if a fieable
FROM TO DIAMETER THICKNESS I MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 70 ft 6.25 i in. 1 #21 1 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
21010108736 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt. in.
List all applicable well permits(i.e.County,State. Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN -
WaterSupplyWelL• FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Mtmicipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT i',
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation p ft' 20 ft- Bentol ite Pumped
Non-Water Supply Well:
ft, ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a livable
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquiter Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwatcr Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1 0 ft- 70 ft. OVER BURDEN
11-9-2021 70 ft. 225 ft• GRANITE
4.Date Well(s)Completed: Well ID#
f:. ft.
5a.Well Location: ft. ft.
DB INVESTMENTS OF NC LLC
Facility/Owner Name Facility ID#(ifapplicable)
18 E NORTHWOODS COURT HENDERSONVILLE, NC 28792PEE 13 rc, rt. -
Phvsical Address,City,and Zip 21.REMARKS
Hendersonville 9690763979
Countv Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification-
(i('well field,one tat/long is sufficient) ) Q0
11/12/2021
N W
Signature orCertifi4fWell Contractor f Dale
6.Is(are)the well(s): ❑✓Permanent or ❑Temporary By signing this form,I herebr certifv 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 ZNo coPy ofthi.s record has been provided to the well owner.
If this is a repair fill out known well construction information and explain the nature ofthe
repair under#21 remarks section or on the back of 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 ifnecessary.
For multiple injection or non-water supply wells ONLY with the saute construction,you can
submil one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple swells list all depths ifdr(ferent(example-3@200'and 2@100') construction t0 the following:
10.Static water level below top of casing: 30 (rt) Division of Water Resources,Information Processing Unit,
4 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) `�
C Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type. PILLS Amount: 25 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