GW1-2022-02910_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This forth can be used for single or multiple wells
1.Well Contractor information:
14.WATER ZONES`
Kolby Mitchell Sawyers FROM TO DESCRIPTION
Well Contractor Name rt. ft.
4471-A
15.OUTER CASING(for multi-cased we11s)OR LINER if a Gcable
NC Well Contractor Certification Number FROM T( DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 101 16.25 11O #21 Pvc
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
21100121859 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#- ft. ft. in.
List all applicable well permits(i.e.County,,State. Variance,Injection,etc.) ft ft in
3.Well Use(check well use): 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Water Supply Well: ft. in.
ft.
❑Agricultural ❑Municipal/Public
ft. ft. in.
❑ m Geotheral(Heating/Cooling Supply) E IResidential Water Supply(single)
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrrieation 0 rt. 20 ft. Bentonite Pumped
Non-Water Supply Well: ft. R.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach addition al sheets if necessar
[]Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 it• 101 ft. OVER BURDEN
2-7-2022 101 ft- 245 ft. GRANITE
4.Date Well(s)Completed: Well iD# tt. ft.
5a.Well Location:
CMH Inc ft. ft.
Facility/Owner Name Facility ID#(if applicable) it. it.
Four Wheel Drive Lot 3 Hendersonville,NC 28792 f� ft. FEB 2-9 20 Z
Physical Address,City,and Zip 21.REMARKS
Henderson 9599789702bW
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
02/18/2022
N W �a "e�= —
Signature of Certify Well Contractor Date
6.is(are)the well(s): ❑O Permanent or ❑Temporary Br signing this form,1 hereby certiJv that the wei/(s)was(were)constructed in accordance
With 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consattction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ZNo copy ofthis record has been provided to the well owner.
11 tlris is a repair.fill out known well construction information and explain the nature of the
r m
epair corder#21 remarks section or on the back of this%rm Yo
. 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 satpply wells ONLY with the same construction,you can SUBMITTAL INSTUCTIONS
subunit one/ormr.
9.Total well depth below land surface: 245 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths r/'di(Jerent(example-3@200'and 2@100') construction to the following:
20 Division of Water Resources,information Processing Unit,
10.Static water level below top of casing: (ft') 1617 Mail Service Center,Raleigh,NC 27699-1617
/Jlruter level is shove casing.use..+..
11.Borehole diameter- 6.25 (in) 24b.For Iniection 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,
L13a.Yield
TER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&Injection Wells:
(gpm) 20 Method of test: RIGAlso submit one copy of this form within 30 days of completion of
fection 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