GW1--06089_Well Construction - GW1_20230921

r Pnnt Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I I
Kolby Mitchel Sawyers 14WATERzori>s ._ •�>�
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
4471-A
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASINO(formgltr casetL*' ils)OR LINER Of licable)-pia , . _.
CLYDE SAWYERS&SON WELL&PUMP INC FROM TO DIAMETER I THICKNESS MATERIAL
+1 ft' 142 ft' 6.25 in' #21 PVC
Company Name 0G5-2023-�076 °16.INNER CASI$C OR TUBING(geothermalclosed loop) „
2.Well Construction Permit#: 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 1O'
Water Supply Well: 17,SCREEN r,.��` - _, _• :,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
10 Agricultural DMunicipa[IPublic ft. ft. in..
X'Geothermal(Heating/Cooling Supply) EtResidential Water Supply(single) ft. ft. in„
XI Industrial/Connnercial DI Residential Water Supply(shared) ",18iGROUT ,a 4,,, .. r, .r t..( , _. ,
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. BentoniteI Pumped
liI Monitoring ORecovery ft. ft. I Cap Top with Bentomite chips
Injection Well:
ft. ft.
I Aquifer Recharge 0Groundwater Remediation
• 19.SAND/GRAVEG"PACK(if applicable)' '
I Aquifer Storage and Recovery DI Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
) [Aquifer Test Ej Stormwater Drainage ft. ft.
X Experimental Technology 0 Subsidence Control ft. ft.
I Geothermal(Closed Loop) ©(Tracer 20.DRILLING LOG(attach:additional'sheets If necessary). - " “
FROM I TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
0 ft. 142 ft- OVER BURDEN
4.Date Well(s)Completed:09/06/2023 Well ID# 142 ft 265 ft' GRANITE
5a.Well Location: ft. ft. �.'
CMH Homes Inc. rt. ft. �-`` tt i< 'V a
Facility/Owner Name Facility IDtt(if applicable) ft. ft.
197 Woodrow Way, Hendersonville,28792 ft. ft. SEP 2 1 2023
Physical Address,City,and Zip ft. ft. •inforir- 1k.:n ;ft,_c- s-9 hr21!
Henderson 9690776375 •21.REMARKS,:>:,. - € . , " " tr a,rzt0 °
County Parcel Identification No.(PIN) phis 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: I
I
N W i 09/08/2023
6.Is(are)the well(s) r i Permanent or ED Temporary Sigma a of Ce ed ontractor Date
By signing th form,I hereby certify that the well(,)was(were)constructed in accordance
7.Is this a repair to an existing well: 3Yes or EiNo with 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction inf rntation 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.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 265 (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(3100) 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
11.Borehole diameter: 6.25 (in.) 24b.For Infection 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 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 6 Method of test: RIG 24c.For Water Supply&Iniectioln 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 the county health department of the county
where constructed.
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016