GW1--06090_Well Construction - GW1_20230921

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WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
I.Well Contractor Information:
Kolby Mitchel Sawyers mcimw,Nrukzong, ,,.. -Ro
FROM TO DESCRIPTION
Well Contractor Name
ft. ft. I 1
4471-A
ft. ft. f
NC Well Contractor Certification Number lS;s{StlC'ERRGAS101 (fifViiititit-castsd'sselli)U1t;t11iEitqif p lle9l te) r
CLYDE SAWYERS&SON WELL & PUMP INC mom TO MAME.PER 'THICKNESS MATERIAL
+1 ft• 28 ft• 6.26 I j 1O #21 PVC
Company Namc
OSS-2022-0416 iNtvEltsC;isYi` sivrumlN6tga berital zoied.looP-
2.Well Construction Permit#: FROM TO , IL1METER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. 1 in.
I.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: f7dSCREEN, 1 ,- a Al,„ %ate''
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
al:Agricultural ®Municipal/Public ft. ft. in.
MI Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft. ft. in.
MI industrial/Commercial OResidential Water Supply(shared) i$;C12OUT ,, 33 s 'glit. -: '
!Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• Bentonite Pumped
*I Monitoring ORecovery ft. ft. Cap Top with Bentomite chips
Injection Well:
ft. ft.
*iAquifer Recharge DGroundwater Remediation
i9;SAND/CRA`l lI'1'ACK(if.appli l Te EMx' f a '1 ti - �
It Aquifer Storage and Recovery 13 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
*I Aquifer Test 0 Stonnwater Drainage ft. ft.
1II1Experimental Technology [3Subsidence Control ft. ft.
•Geothermal(Closed Loop) ®Tracer 21t:bii11;1:INCH,HOC,{aitack'°ddiTi natsheets" Pirecesiaii5'��>:s*=
FROM TO DESCRIPTION(color,hardness,soilrock type.grain size,etc.)
a Geothermal(Heating/Cooling Return) [3 Other(explain under#21 Remarks)
o ft. 28 ft• OVER BURDEN
4.Date Well(s)Completed:7-25-2023 well ID# 28 ft, 805 ft* GRANITE
5a.Well Location: ft. ft.
KATHRYN CARROLL ft. ft. " t. If.;iv V t •,i
Facility/Owner Name Facility ID#(if applicable) ft. ft.
849 SUGARLOAF MTN ROAD HENDERSONVILLE, NC 28792 ft. ft. SEP 2 1 2023
Physical Address,City,and Zip ft. ft.
HENDERSON 0611625518 ilttimma,,AL ,'- VOWD,MCOZWAIMIta
County Parcel Identification No.(PiN) this well was self certified
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell field,one IaUlong is sufficient) 22.Certification: I
N N' I', . _ 8-10-2023
6.Is(are)the well(s) Permanent or [3Temporary Signa e of er edlh ontractor Dale
X
By signing th Orrin,I hereby certify'that'the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or x( No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
1f this is a repair,.fill out known well construction information and explain the nature of the copy of this record has been provided iolthe well owner.
repair under#21 remarks section or on the back of this fetrm.
23.Site diagram or additional well details:
8.For Ceoprobe/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 2100) construction to the following: 1
10.Static water level below top of casing: 140 (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 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 denier,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 the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016