GW1-2022-02918_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers FR.VVATERZ011E3 : P,TII
FROAI TO DE SCRIP
Well Contractor Name ft. ft. Z-
4471-A ft. ft. Prm,­^lng Unit
NC Well Contractor Certification Number 15.'OUTER ultiftfiw,we.. .a licable
FROM TO DIAMETER E S MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 157 a• 6.25 1 ' in #21 1 PVC
Company Name .46.'INNER CASING OR T ING etithermal.closed-loo �,;`. '.
2110011 909 FROM TO DIAMETER THICKNESS 51ATEMAL
2.Well Construction Permit#: a9 ft. ft, in.
List all applicable well permits(i.e.County,State.Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use):
;J7♦SCREEN >:-
Water Supply Well: FROM TO DIAMETER SLOT SIZF. THICKNESS MATERIAL
ft. ft.❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) OResidential Water SuPPIY(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL" EMPLACEMENT METHOD&AMOUNT
❑Irri ation 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 a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necess `
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 57 ff. OVER BURDEN
02-02-2021 57 ft- 205 ft- GRANITE
4.Date Well(s)Completed: Well iD# w
-
5a.Well Location:
Jaun Chavez ft. ft. -
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
43 Morning Lane '
ft. ft. ems'
Physical Address,City,and Zip �t r7e
21 REMARKS',
I -
Hendersonville 9680700232
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 02/02//2022
Signature of Cenifi Well Contractor Date
6.Is(are)the well(S): ❑✓Permanent or ❑Temporary Br signing this roan,I hereby certifv that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or i5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy 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 on the back ofthis 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 ifnecessary.
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: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(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,
ifwater 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 24aabove, 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 ResourcesV Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1
13a.Yield m 20 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: 35 well construction to the county health department of the county where
constructed.
i
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013