GW1-2021-00214_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Kolby Mitchell Sawyers FRO ATERZONES DESCRIPTION
Well Contractor Name
4471-A rt.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a ticable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft 50 rt• 6.25 #21 1 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
20100122421 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable eel/permits(i.e.County,State.Variance,Injection,etc.) ft ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT S17E THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑MunicipaUPublic
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPIY(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 rt. 20 ft- Bentonite Pumped
Non-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 necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 50 ft. OVER BURDEN
7-9-2021 50 f` 105 f`• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft.
BOYD HYDER ft. ft. DEC 13 20
Facility/Owner Name Facility ID#(if applicable) ft ft
67 CLARK ROAD Hendersonville, NC 28792
Phvsical Address,City,and Zip 21.REMARKS '
Henderson 9690767823
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification•
(if well field,one lot/long is sufficient) •
N W 7-20-2021
Signature of CertilI Well Contr actor Date
6.Is(are)the well(s): ❑✓Permanent or ❑Temporary BY signing this form,I hereby cent fv that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or KNo copy gfrhis record has been provided to the well owner.
ll'Ihi.s iv a repair,Jill our known well construction information and explain the nature of the
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 if necessary.
For malliple injection or non-water supply wells ONLY with the same construction,you can
snhnil one/'arm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 105 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths il'Qjerent(example-3 eCi 200'and 2@a 100') Construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
Ijlmter 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.anger,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) 30 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• 20 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