GW1-2022-05287_Well Construction - GW1_20220526

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers FRO ATERZONES DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased.wclls)OR LINER(if a ficabh"
FROM I TO I DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft 75 ft• 6.25 i #21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
21100119380 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State, Variance,Iqliection,etc)
ft. rt. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal Heating/Cooling Supply) El Residential Water Supply(single) ft. ft. m
( a o PP Y) PP Y( g )
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 fc. 20 ft- Bentonite Pumped
Non-Water Supply Well:
rt. rt.
❑Monitoring ❑Recovery
Injection Well: tt. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL'PACK if a licablc
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑TIacer FROM TO DESCRIPTION color,hardness,soil rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) El Other(explain under 921 Remarks)J 0 ft. 75 ft. OVER BURDEN
4-27-2022 75 ft- 265 ft. GRANITE
4.Date Well(s)Completed: Well ID#
fc. rt.
Sa.Well Location:
Nehemias Delores ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. u ..
599 Pace Road Hendersonville, NC 28792 ft. rt. MAY
Physical Address,City,and Zip 21.REMARKS
Henderson 9680901786
County Parcel Identification No.(PIN) j 'i 'r'• ^
5b•Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one]at/long is sufficient)
i�� ) (.2(1 05/03/2022
N W
Signature ofCertifi Well Contractor Date
6.15(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Mell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided to the well owner.
?(this is a repair,Jill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back o/'1hisJor1n. 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,loan. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple n•ells list all depths ifdi(/erent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 50 (ft) Division of Water Resources,Information Processing Unit,
i/lvater level is ahove casing,use•'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection 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 4 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: 30 well construction to the county health department of the county where
constructed.
Forp.i GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013