GW1-2022-07721_Well Construction - GW1_20220819

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This limn can be used for single or multiple wells
1.Well Contractor information:
14.WATER ZONES
Derrick Heath Sawyers FROM TO DESCRIPTION
Well Contractor Name ft. ft.
t
2436-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-ease}d wells)OR LINER if a Gcable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 68 ft' 6.25 i #21I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed400
22100102436 FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable n'ell permits(i.e.Count),,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
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Cooling Supply) OResidential Water Supply ft. ft. in.( b/ b PP Y) PP Y
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 1" 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 ft. ft.
❑Aquifer Test ❑Stonnwatcr Drainage
tc, ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gnin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 68 ft. OVER BURDEN
6-23-2022 68 tt. 485 tt. GRANITE
4.Date Well(s)Completed: Well iD#
ft. ft.
Sa.Well Location:
Stanley Livingston ~-
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
488 John Delk Road Hendersonville, NC 28792 AUG _
ft, ft. ;,
�r`t^ ir�. Rn
Phvsical Address,City,and Zip 21.REMARKS v+e:rm� •r� - ,
Henderson 0610292099
Countv Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W 6-28-2022
Signature of Certified Well ContractooF Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this form,I hereby certify that!the well(s)was(were)constructed in accordance
With 15A NCAC 02C.0I00 or 15A NCAC 02C.02t10 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or KNo coP),q/this record has been provided to the well owner.
If'this is a repair.fill out known well construction inlorrnalion and e.rplain the nature of the '
repairunder#21 remarks section or on the back o(this/orn. 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 nathiple injection or non-crater svtpp/v wells ONLY with the sane construction,you can
cuhmil One/brin pG SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 485 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welts list all depths i/'dijlerent(example-3(:cD,200'and 2@I00') construction to the following:
10.Static water level below top of casing: 60 Division of Water Resources,Information Processing Unit,
(ft.)
It trzaer level is above casing.use'+" 1617 Mall 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 Cent i er,Raleigh,NC 27699-1636
m 13a.Yield
(gP ) 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: 35 well construction to the county healtA department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013