GW1--06088_Well Construction - GW1_20230921

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Derrick Heath Sawyers I :wATEItikoN s w; m , t
FROM TO DESCRIP,HON
Well Contractor Name
ft. ft. I I
2436-A ft. ft. i
NC Well Contractor Certification Number h^IS:;OUTER CASING(for multi cased thells)OR LiNER Of aj livable) , ,It
FROM TO DIAMETER! THICKNESS MATERIAL ,
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 118 ft- 6.25 I iin• #21 Pvc
Company Name .t6i:INNERICASING,ORTUI)ING-,(geothermal.closedloop);: „`�...,�-
055-2023-1082 FROM TO DIAMETER. , THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use):
.47ySGREEN _.. ?.^ ,��� _,. .3 _. � .... n. 4^ ; .6t
Water Supply Well: FROM TO DIAMETER' SLOT SIZE THICKNESS .MATERIAL
ID Agricultural ❑Municipal/Public ft. ft. in:
❑Geothermal(Heating/Cooling Supply) PResidential Water Supply(single) ft. ft. in'i
1$:GXtt,)UT ,�,t' ,_ -" _ "
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft, 20 . ft• Bentonite Pumped
Non-Water Supply Well: ft. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation -19.SAND/GRA L PACR(iffapptltfilile). • ,,
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft. I
❑Experimental Technology ❑Subsidence Control ',20:DRILLING LOG(attach:"aitdititiail5heet"s:if_necessary) ")_,,
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiUrocktvpe,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 118 ft• OVER BURDEN
09/06/2023 118 ft• 225 ft. i' GRANITE
4.Date Well(s)Completed: Well DM- ft. ft.
5a.Well Location: ft. ft. .. i' °a y } -;
CMH Homes Inc ° '4,, t._g • :w.1.;
ft. ft.
Facility/Owner Namc Facility ID#(if applicable) ft. ft. S E P r 20G
3
202 Woodrow Way, Hendersonville 28792 ft. ft.
Physical Address,City,and Zip
If •ram r"� �e r z ll;2I:REMA k_ , _= . „„ ,,
Henderson 9690870235
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 t 09/08/2023
Signature ofLlerial"„,,,,,S
ertifed Well Contracts/ Date
6.Is(are)the wll(s): OPermanent or 0 Temporary
By signing this firm,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo 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 wider#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: 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: 225 (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@I00') construction to the following:
10.Static water level below top of casing:25 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use'±" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY:I 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,IUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ci nter,Raleigh,NC 27699-1636
7 RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:_PILLS Amount: 20 well construction to the county health department of the county where
constructed.
Form GW-i North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013