GW1-2022-02919_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
i
I.Well Contractor information: ,
59
Kolby Mitchell Sawyers 14.FROM ER ZONES T i
FROM TO DESCRIPTION
Well Contractor Name ft. ft. 1 W
4471-A ft. ft. h4o€ iat an Praczzr,�ng Unot
VC Well Contractor Certification Number 15.OUTER CASING for multi-cased'.wills)OR cable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft' 66 ft 6.25 I i" #21 PVC
Company Name 16.INNER CASING OR TUBING iothermal closed-loop)
21100104651 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
Water Supply Well: FROM ro DIAMETER SLOT SIZE THICKNESS MATERAAI.
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Su 1 ElResidential Water Supply ft. ft. in.
PP Y) PP Y
❑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/CRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Storrnwater 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,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)J 0 ft- 66 ft. OVER BURDEN
1-31-2022 66 rt 145 ft GRANITE
4.Date Well(s)Completed: Well ID#_
5a.Well Location: ft. ft.
Darin Pace ft. ft.
Facility/Owner Name Facility ID#(ifapplicable)
rt. rt.
Pearl Owenby Property Lot 3 Hendersonville, NC
n. n.
Phvsical Address,City,and Zip 21.REMARKS
Henderson 9589792492
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 2-2-2022
Signature of Cer ifi Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
with 15A 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 ElNo cvtnr ofthis record has been provided to the well owner.
I/this is a repair,fill out knoirn well construction in%rmalion and cuplain the nature ofthe
repair under#21 rentarkt section or on the back of'rhis firm. 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.
Fur multiple injection or non-wales supply wells ONLY with the scone construction,you can
suhmit on form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 145 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@1 construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
//%cater 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,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:
(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.
Fort 6 W-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013