GW1-2022-02913_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD For Internal Use ONLY: B
This form can be used for single or multiple wellsr ti
I.Well Contractor Information:
Kolby Mitchell Sawyers 14.WATER ZONES i
FRO\I "1'O DESCRIPTION
Well Contractor Name ft. ft. (r;pf 3:Y:i� alis`aa
4471-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wetls)OR LINER if a 6cable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 60 ft' 6.25 1 in. 1 #21 1 PVC
Company Namc 16.INNER CASING OR TUBING(geothermal closed-loop)
21100114330 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. H. in.
List all applicable well 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 SLOTSIZE 'THICKNESS MATERIAL
rt. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Coolingo Supply) EIResidential Water SuPP1Y(single) ft ft in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
El Irrigation 0 ft. 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 ❑Stonnwater Drainage
ft. ft.
❑Experinmcntal Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessat•
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiltrock type,pritin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 60 ft. OVER BURDEN
12-13-2021 60 ft• 185 ft. GRANITE
4.Date Well(s)Completed: Well iD#
rt. rt.
5a.Well Location: ft. R.
Seth Solesbee ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
143 Walt Drive Hendersonville, NC 28792 ft.
Physical Address,City,and Zip 21.REMARKS
Hendersonville 0509188437
County Parcel Identification No.(PIN)
51).Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one hat/long is sufficient)
N N 12-15-2021
Signature of Cer ifi Well Contractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this form, I herebv cert fv that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15.4 NC4C 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo cony gfthis record has been provided to the well owner.
If this is it repair.fill out known well construction information and erplain the nalare of the
repair under#21 remarks section or on the back gfthis_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.
Fur multiple injeetion or non-water supphv wells ONLY with the sate construction,iron can
suhrnit One,forrn. 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 ur/Is list all depths it'dr/ferent(example-3@200'and 20a)100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
if eater level is above easing,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 oftest:
6 RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13h.Disinfection type: PILLS Amount: 20 well construction to the county health department of the county where
constructed.
Foram GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013