GW1-2022-06137_Well Construction - GW1_20220628

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
'A 1.Well Contractor informattiion:
KOlby Mitchell Sawyers 14.
FROM ER ZONES j
RODI TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft. ft.
NC Well'Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR tip lica LINER(if ble
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 132 ft 6.25 #21 1 PVC
Company Name 16.INNER CASING OR TUBING(eothermal closed400 -
21100116540 FROM TO IA DMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List till applicable nr/lpermits(i.e.Counq,,State.Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
[]Geothermal(Heating/Cooling Supply) 7Residential Water SuPP1Y(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑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 El Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
tt. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets ifnecessar ;
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 132 ft. OVER BURDEN
5-31-2022 132 ft 245 ff• GRANITE
4.Date Well(s)Completed: Well ID#
ft. rt.
Sa.Well Location:
Charles Capps
Facility/Owner Name Facility iD#(if applicable) ft. rt. J U N 2 S 2
263 Pleasant Meadow Lane Hendersonville,NC 28792Unh
Physical Address,City,and Zip 21.REMARKS
Henderson 9589853927 T
County Parcel Identification No.(PIN)
ib.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N N (XI 6-13-2022
Signature of Certifity Well Contractor Date
6.is(are)the well(s): ❑O Permanent 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 Well Constniction Standards and that a
7.Is this a repair to an existing well: ❑Yes or F1No coPy ofthis record has been provided to the well owner.
l(thit is a repair,fill aml known well construction hi rination and erplain the nature of the
repair corder#21 remarks section or on the back o(thisform. 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: construction details. You may also attach additional pages ifnecessary.
For multiple h jection or none-water supplt•wells ONLY with the same construction,van can
submit one farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 245 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For undliple n•el/s list all depths i/'dijjerent(example-3(a)700'and 2@100') construction to the following:
10.Static water level below top of casing: 40 Division of Water Resources,Information Processing Unit,
1j'u-ater level it above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection 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• 25 well construction to the county health department of the county where
constructed.
Fort GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013