GW1-2023-01981_Well Construction - GW1_20230227

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This lorm can be used for single or multiple wells
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1.Well Contractor Information:
14.WATER ZONES
Kolby Mitchell Sawyers FROM 'to DESCRIPTION
Well Contractor Name ft. ft. I'
4471-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased•svells)OR LINER(if a Gcabb"
FROM TO DIAMETER I THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 70 ft. 6.25 i1 #21 PVC
Company Name '16.INNER CASING OR TUBING eothermal closed-too =
055-2022-0475 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List till applicable it-ell permits(i.e.County,State,I4a•iance,h jection,etc.) in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER i SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) EIResidential Water SuPP1Y(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD At AMOUNT
❑Irrigation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. rc.
17 Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation 1%SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwatcr Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLINGLOG(attach a8ditional'sheets if necessary)
❑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 70 ft " OVER BURDEN
12-27-2022 70 ft- 165 ft GRANITE
4.Date Well(s)Completed: Well ID# ft. ft. !
,a.Well Location:
CMH Homes ft. ft.
Facility/Owner Name Facility ID#(if applicable)
78 Woodrow Way Lot 2 Hendersonville, NC 28792
Ic. ft.
Phyaical Address,City,and Zip 21.REMARKS FEBt
Henderson 9690870005
COWIN Parcel Identification No.(PIN) Ini`. 4 c;a a r 4.r+raa !r to
-b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification
61'well field,one lat/long is sufficient)
1-11-2023
N W V-'A - ) (-'-J
Signature orCertifi Well Contractor Date
6.Is(are)the well(s): QPermanent or ❑Temporary
By signing this form,1 herebv certiJv tlfa(the we/l(s)was(tivere)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 ©No cope qf1his record has been provided to the well owner.
lfthis is a repair,,lill out known well construction information and erplain the nature ofthe
repair under#21 remarks section or at the back gl'this•form. 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-tvater supply wells ONLY with the same construction,you can
wbmil n/le form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this!foam within 30 days of completion of well
For multiple wells list all depths ifdiftrent(example-3@—)700'and 2@100') construction to the following:
10.Static water level below top of casing: 30 Division of Water Resources,Information Processing Unit,
(ft.)
11'n'ater•level is 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'n
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ROTARY 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
t 1
13a.Yield(,-pm) 15 Method of test: RIG 24c.For Water Supply&In,jectioniW,ells:
,
Also submit one copy of this form' within 30 days of completion of
PILLS
13h.Disinfection type: Amount: 20 well construction to the county hen rlth department of the county where
constructed. +I
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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