GW1--06082_Well Construction - GW1_20230921

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers •1 s i S r ° � , :'
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
4471-A ft. ft I
NC Well Contractor Certification Number >
�.1i1�;7�"131ttIlvCr{t"o mtti�ea"s�i: ell,)..t1Rt�1Ee�{l��p licah�te3 ,fI:
CLYDE SAWYERS&SON WELL&PUMP INC FROM 'ro IIAMEl'ER' 'THICKNESS MATERIAL,
+1 ft. 79 ft 6.25 1. In. #21 PVC
Company Name
xtb�'.I l`fittaS I Y R'C1;OIN .t x*M
,n t(f�lus`bd,(Otijs}•.... �s5 . i
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2.Well Construction Permit#: OSS-2023-�109 FROM TO DIAMETER THICKNESS MATERIAL _
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. I in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM TO DIAMETER' SLOT SIZE TRICKINESS MATERIAL
®iAgricultural EiMunicipal/Public ft. ft. in,I
1
*'Geothermal(Heating/Cooling Supply) E3 Residential Water Supply(single) ft. ft. in.;
xi industrial/Commercial OResidential Water Supply(shared) f t i 1) , - . ,i. ..:
'Irrigation . FROM TO h1ATERI.AL EMPLACEM ENT METHOD&AIIIOUN'I'
Non-Water Supply Well: 0 ft 20 ft. Bentonite Pumped
!Monitoring °Recovery ft. ft. Cap Top with Bentomite chips •
Injection Well:
ft. ft.
!Aquifer Recharge ®Groundwater Remediation
) 'Aquifer Storage and Recovery ®Salinity Barrier FROM TO MATERIAL _ EMPLACEMENT METHOD
'Aquifer Test 0 Stonnwater Drainage ft. ft.
II Experimental Technology ®Subsidence Control ft. ft. '
(ClosedLoop) � t1i �O k4a� d lil�al sit"ee5safaeeViii ' W
!Geothermal Tracer
FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
Geothermal(Heating/Cooling Return) DOther(explain under#2I Remarks)
0 ft. 79 ft. OVER BURDEN
4.Date Well(s)Completed:8-7-2023 Well ID# 79 ft 225 ft. ` -
PGRANITE . c-a r li:-7\ I'�
5a.Well Location: ft. U. VZ b t.,,L..i'' V L..i..
JOHN MARK LEWIS ft. ft. iSEP 2 1 2023
Facility/Owner Name Facility 1D#(if applicable) ft. ft. j
1862 SUGARLOAF MTN ROAD HENERSONVILLE, NC 28792 ft ft. j ►nrti`^��'` iz"�''�('r
r',�♦f •St 1
Physical Address,City,and Zip ft. ft.
HENDERSON 0621034791 42lRl if1R . ;s �� '
County Parcel identification No.(PiN) this well was self certified
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N " 8-8-2023
6.Is(are)the well(s) Permanent or °Temporary Signa e of er ed ontractor Date
X
By signing th ortm,I hereby certifj'that the well(s)was(were)constructed in accordance
7.is this a repair to an existing well: 0 Yes or ONo with I5A NCAC 02C.0100 or 15A NCA(02C.0200 Well Construction Standards and that a
If this is a repair.fill out knonm well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
I ,
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 225 (ft-) 24a. For All Wells: Submit this I•form within 30 days of completion of well
For multiple wells list all depths ifd�erent(example-3@200'and 2@100') 1
construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resou Ices,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b•ForIniection Wells: In addition to sending the form to the address in 24a
ROTARY above,also submit one copy of this fiirm within 30 clays of completion of well
12.Well construction method: I
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: In addition to sending the form to
the address(es) above, also submit!one copy of this form within 30 days of
13b.Disinfection type: PILLS Amount: 25 completion of well construction to'the county health department of the county
where constructed.
Form CiW-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016