GW1-2022-02916_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD For Internal Use ONLY: �rr. ��A
This form can be used for single or multiple wells 5 'r am V I 3
I.Well Contractor Information: �d
14.WATER ZONES
Kolby Mitchell Sawyers FROM TO DESCRIPTION
Well Contractor Name ft. ft. jnforwm4i-xl P rOi, ;x img Unit
ft. ft. +
4471-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER(if a licable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 51 ft 6.25 #21 1 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
21100114181 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Counn,,.State. Variance,htilection,etc.) ft. ft.
in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE 'I'HICKNF.SS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ElResidential Water SuPP1Y(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft. 20 {t• Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑N9onitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑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/mck type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft. 51 ft. OVER BURDEN
12-14-2021 51 ft 145 ft GRANITE
4.Date Wells)Completed: Well ID#
ft. ft.
,a.Well Location: {t, {t,
Amanda Moss
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Stepp Mill Road Hendersonville, NC 28792 111. ft.
Phvsical Address.City,and Zip 21.REMARKS
Hendersonville 9599778366
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 &AA 12-28-2021
Signature ofCertifi Well Contractor Date
6.Is(are)the aell(s): OPermanent or ❑Temporary By signing this form,l hereby certifb that the well(s)was(were)constructed in accordance
with I5A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy gfthis record has been provided to{he well owner.
llthis is a repair./ill out known well construction iglormalion and e.vplain the:nature of the
repair under N21 remarks section or on the hack o/'this,joon. 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 nuthiple injection or non-water svpplr wells ONLY with the same construction,you can
submit one loon. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 145 ({t,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple a ells list all depths ij di/lerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
/linter 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.auger,ro(ary,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
I3a.Yield m 15 Method of test: RIG 24c.For Water Supply&Injection Wells:
(gP ) 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.
Foram GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013