GW1--06087_Well Construction - GW1_20230921

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: , ;
Derrick Heath Sawyers FROM TO DESCRIPTION
°� °<
14`wATER2t� r.�r . . .�.
ON
Well Contractor Name ft. ft.
2436-A ft. - ft.
NC Well Contractor Certification Number _15.O11TER`CASING(Iorhiulti.ci ttwells)ORLiNER(It'`lpplreable),s°'. i ''xi:
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 41 ft• 6.25 ,: in' #21 PVC
Company Name <I6JNNERCAS1NG'OR<TIMING"(jhdlherma1'tlosed loopj,"7;` r. .,..
055-2023-0811 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. 1 in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft ft. in.
3.Well Use(check well use): 417iSCREEN c . 1 r.W:.;:.x . __,f„ :
Water Supply Well: FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. ft. in!
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18 e41tt�Utt °'„'" A;' 'a �_ � `� '^'.t„ ,�' ' ''�' 'i
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft• 20 ft. Benton,'ite Pumped
Non-Water Supply Well:
ft. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery •
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation tA:SMBlCiraI:;3'AGW(if.dliPliCatik} t., a
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stonmvater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
t120i'DRILLING-LOG'(attacb``addltional beets if necessary),- ..:9 .:
OGeothermal(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• 41 ft• OVER BURDEN
09/06/2023 41 ft• 105 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft. R It!-rr 1::Rt V i E L,
Roger Canales ft. It.
ft. ft.
Facility/Owner Name Facility 1D#(if applicable) S E P 2 �_ 2023
137 Woodrow Way, Henderson 28792 ft• ft.
I Inff ,Er;,�;r r1 ,7 Ijr.21
Physical Address,City,and Zip ', i , «r iP TM- ,
,21:RRh1ARKS, ,.. w„..�,.r.,.. , .� a�� 4i��`'t�, s,�,ab� *t., !1'
Hendersonville 10009237
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W S f
09/08/2023
Signature of ertified Well Contracto/, Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: :Wes or ENo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of 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 if necessary.
For multiple injection or non-water supply wells ONLY with the.same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 1 05 (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@l00) construction to the following: i
10.Static water level below top of casing:20 (ft.) Division of Water Resources,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.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 Center,Raleigh,NC 27699-1636
(gpm) 30 RIG 24c.For Water Supply&Injection Wells:
m 13a.Yield Method of test: ,
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 20 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013