GW1--06084_Well Construction - GW1_20230921

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: •
+
1.Well Contractor Information: I i
Kolby Mitchel Sawyers A4 W*11EltioN« ,„-Ok1V. "
FROM TO DESCRTP,T1ON
Well Contractor Name ft. ft.
4471-A
ft. ft.
NC Well Contractor Certification Number f 1 D!t tt f V{tp it c StttWiigkbft # ttt4fr ti ift'fi e �
CLYDE SAWYERS&SON WELL&PUMP INC FRONI •1'O DIANIN:I•ERI 'THICKNESS MATERIAL
Company Name +1 fL 65 ft. 6.25 I 110 #21 PVC
I NNER CASiNeDBAU1811�i",ealliC.aiiNtase t-; N' WI
2.Well Construction Permit#: OSS-2023-0636 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft. in.
' fliTSGREEN -;,,._ 1 ' .. '. '' IRMIt
Water Supply Well: FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
$'Agricultural Municipal/Public ft. ft. in.
*'Geothermal(Heating/Cooling Supply) et Residential Water Supply(single) ft. ft. in.
*'industrial/Commercial OResidential Water Supply(shared) 748wifoo kA _
..l irrigation FROM TO MATERIAL EMPLACEMENT METHOD&ANIOUN'I'
Non-Water Supply Well: 0 ft. 20 ft. Bentonite Pumped
AI I Monitoring ()Recovery ft ft. Cap Top with Bentomite chips
Injection Well:
ft. ft.
I Aquifer Recharge E3GroundwaterRemediation r „
igiUN➢iti*AVELIACK>(if iit iktiba l � 7 � •
*1 Aquifer Storage and Recovery DSalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test fI ft.
q E3Stonnwater Drainage
®I Experimental Technology E3Subsidence Control ft. ft.
jr'Geothermal(Closed Loop) ,•Tracer �tb.>131>r1I,'L1'.,avot(actaelraiddjitran'aCsiteeis-tf rrte ae ssa"`ii) a -
FRONT TO DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
+Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft. 65 ft• OVER BURDEN
4.Date Well(s)Completed:8-2-2023 Well ID# 65 ft. 505 ft. GRANITE
�...
5a.Well Location: ft. ft. "' '� q
Linda McGarry ft. ft. L ;'
Facility/Owner Name Facility ID#(if applicable) ft. ft. ' SEP 9 1 2U2
Simply Grateful Drive Hendersonville, NC 28792 ft ft. SEP
!fSR....,_:?..ri tt r,` ,,,ra;',a cif'.
Physical Address,City,and Zip ft. ft �cam + ,
Henderson 0621016636 tlintEmAitKs4 OWPWAIMVZ ' . : O
County Parcel identification No.(PiN) this well was self certified
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W
8-4-2023
6.Is(are)the well(s) Permanent or ®Temporary Signa e of er ed onlraclor Dale
X
By signing di Orin,I hereby certify that the well(s)wits.(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or % No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair.fill out knornt 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 r f this form. i
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.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 805 (ft-) 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple wells list all depths if different(example-3@,200'and 2(#100') construction to the following: I'
10.Static water level below top of casing: 160 (ft.) Division of Water Resources,information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 2 769 9-1 61 7
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells: in addition to sending the form to the address in 24a
ROTARY above,also submit one 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.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service r Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1/2 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: 35 completion of well construction to thie county health department of the county
' where constructed.
Form CAW-1 North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-2016