GW1-2022-03954_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATERZONES
KOlby Sawyers
FROM "1'O DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if.a Geable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 180 ft- 16.25 i 1" #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-lob
20100104288 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 TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Auricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) El Residential Water SuPP1Y(single) ft. ft. in.
_.
❑Ind ustrial/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: ft. ft.
❑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.
❑LxperimentalTechnology ❑Subsidence Control
20:DRILLING LOG attach additional sheetsif necessar -
❑Geothenml(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(ex lain under#21 Remarks) 0 ft. 80 ft. OVER BURDEN
3-8-2022 80 ft- 305 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: H. ft.
Aggressive Properties ft. ft. fir,
facility/Owner Name Facility ID#(if applicable)
Fish Lake Drive Lot 8 Hendersonville, NC 28792 ft. ft.
Pbvsical Address,City,and Zip 21.REMARKS
Henderson 9672198309
Countv Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certifc 'on:
lifwell field,one]at/long is sufficient)
3-16-2022 N N
ignamre ofteffiffeL Well Contract Date
6.Is(are)the well(s): OPermanent or ❑Temporary Br signing this form,I herehv certify 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 ONo cant'of this record has heen provided to the well owner.
If IN.,is ar repair.fill mu known well construction inli-ntation and evplain the nature ofthe
reynur under#21 remarks section or on the hack ofrhis.1brm. 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 multiple irrjecliun ur nun-water supply wells ONLY with the sane construction,you can
suhmil one form. SUBMITTAL INSTUCTIONS
9.'I'otal well depth below land surface: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i/'different(example-3 a 200'and 2 a)100') construction to the following:
10.Static water level below top of casing: 40 (ft•) Division of Water Resources,Information Processing Unit,
If ia,ter 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:
f i.e.auger,rotarv,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
6 of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 30 well construction to the county health department of the county where
constructed.
i
Forum G W-I North Carolina Department of Environment and Natural Resources-Division of water Resources Revised August 2013