GW1-2022-02915_Well Construction - GW1_20220228

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WELL CONSTRUCTION RECORD For Internal Use ONLY: Rf
This form can be used for single or multiple wells FEB `�0ZZ
1.Well Contractor Information: I f t_uu
14.,WATER ZONES 11 ..
Kolby Mitchell Sawyers FROM 'to DESCRIPTION
Well Contractor Name
ft. ft.
4471-A ft.
NC Well Contractor Certification Number 26
15.OUTER CASING Tor mul&cased"wells OR LINER if a licable
FROM TO DIAMETER. THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 88 ft- 6.25 ' #21 1 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loci "' _
21100118717 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt. in.
List all applicable well permits(i.e.County.State.Variance,h jection,etc.)
ft. ft. in.
3.Well Use(check well use): .17.�SCREEN, .;;e
Water Supply Well: FROM '1'0 DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft.❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20 rt. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHODtt tt
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)',
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type min size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 tt. 88 ft. OVER BURDEN
12-21-2021 88 ft. 185 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Andrew Moss
Facility/Owner Name Facility ID#(if applicable)
Stepp Mill Rd., Lot 1 rt.
Physical Address,City,and Zip
21.REMARKS
Hendersonville 9599788752
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)
N W 12/22/2021
Signature ofCertift Well Contractor Dale
6.Is(are)the well(s): ❑✓Permanent or ❑Temporary By signing this form,I herebP cert�that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo corn ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or an 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: construction details. You may also'attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. 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 wells list all depths ifdijferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b. For Infection Wells ONLY:i 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 m 15 Method of test: RIG 24c.For Water Supply&Injection Wells:
tgp ) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 35 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