GW1-2022-06139_Well Construction - GW1_20220628

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This corm can be used for single or multiple wells
I.Well Contractor Information:
14.
Kolby Mitchell Sawyers FROM ATERZ ONES DESCRIPTION
Well Contractor Name ft. ft.
4471-A tt. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a Gh able)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 85 ft. 6.25 #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-too '
21120103956 FROM TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: tt. ft. I in.
List all applicable well permits(i.e.Couno,,State, Variance,hjection,etc.) ft ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL,
in.
❑Agricultural ❑Municipal/Public ft. ft.
❑Geothermal(Heating/Cooling=Cooling Supply) El Residential Water Supply(single) ft. ft. in.
( t� b PP Y) PP Y( g )
❑Indu FR
strial/Commercial ❑Residential Water Supply(shared) GROUT
OJI 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 applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier tt rt
❑Aquifer Test ❑Stormwater Drainage
rt. rt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 85 ft. OVER BURDEN
4-28-2022 85 ft• 225 ff• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Erin Galloway
Facility/Owner Name Facility ID#(if applicable)
Shadow Ridge Drive Hendersonville, NC 28792 rt. rt.
N 2 g 2022
Physical Address,City,and Zip 21.REMARKS.
Henderson 9673371343 info,mia,ion Prc;:�-g Urtft
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
N N 6-7-2022
Signature of Certifn Well Contractor Date
6.Is(are)the well(s): ❑Permanent 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 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo cop}'of 1his record has been provided to the well owner.
{fihis is a repair,./ill nut known well constriction information and tarplain the nature ofthe
repair under#21 remarks section or on rite back o/'this fora. 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 nnr/tiplc injeetion or non-water supply wells ONLY with the same construction,tint can
submit nneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nudtipte wells list all depths i('dtftrent(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing: + (ft.) Division of Water Resources,Information Processing Unit,
i/lrater level is above 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(gpm) 5 Method 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• 25 well construction to the county health department of the county where
constructed.
For-t GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013