GW1-2022-02904_Well Construction - GW1_20220228

W ELL CONSTRUCTION RECORD For Internal Use ONLY: r-
This form can be used for single or multiple wells it
I.Well Contractor Information:
Kolby Mitchell Sawyers 14.WATER ZONES
FROM TO DESCRIPTION IpApr= 1'
Well Contractor Name ft. ft.
�•
4471-A
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if a linable)
FROM TO I DIAMETER' THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. 78 ft. 6.25 #21 PVC
Company Name 16.INNER CASING OR TUBING 'eothermal closed-loop)
21100119732 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt. in.
List all applicable well permits(i.e.Counm..State. Variance,hyection,etc.) in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZF. 'THICKNESS MATERIAL
ft. ft, in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
❑Industrial/Comm FR
ercial ❑Residential Water Supply(shared) GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft, Bentonite Pumped
Non-Water Supply Well:
❑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,soillmck type,grain site,etc.)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 421 Remarks) 0 ft- 78 ft. OVER BURDEN
1-28-2022 78 ft 245 it GRANITE
4.Date Well(s)Completed: Well iD#
ft. ft.
5a.Well Location:
CMH Homes Inc ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Asher Oaks Lane Lot 4 Hendersonville, NC 28792
rt. rt.
Physical Address,City,and Zip 21.REMARKS
Henderson 0509050629
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification•
(il well field,one tat/long is sufficient)
N WV7�
2-1-2022
Signature of Cettifi Well Contractor J Date
6.is(are)the well(s): 2Permanent or ❑Temporary Br signing this form,1 hereby certJv that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 01C.02t10 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofthis record has been provided to the well owner.
111hi.s is repair,fill and known w information
well consirttction inrmation and evplain the nature gfthe
repair under#1/remarks section or on the hack o/7his 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.supphv wells ONLY with the same construction,you can
SUBMITTAL INSTUCTIONS
submit one form.
9.Total well depth below land surface: 245 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
17or multiple wells list all depths i/'Qjerent(example-3 a 200'and 2@/00') construction to the following:
10.Static water level below top of casing: 40 (ft) Division of Water Resources,Information Processing Unit,
If 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:p in addition to sending the form to the address in
ROTARY 24a above, also submit a copy o(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:
4 RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this fore within 30 days of completion of
13b.Disinfection type: PILLS Amount: 25 well construction to the county heIalth department of the county where
constructed.
For+tt G W-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013