GW1--07537_Well Construction - GW1_20231121

'' Print f9it. i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1
1.Well Contractor Information: 1. ,
Kolby Mitchel Sawyers 44:`WATERZONEs,•
Well Contractor Name FROM To DESCRIPTION
4471-A ft. ft.
ft. ft. f
NC Well Contractor Certification Number
.15.1OthTEWCASINO(for multi-cased:wells)OR.LINER(if"a iTcable) `'
CLYDE SAWYERS &SON WELL&PUMP INC FROM TO DIAMETER ' THICKNESS MATERIAL
+1 ft. 90 ft. 6.25 i. in. #21 PVC
Company Name CASING OR T �_
22120112177 •16.INNER ' UURING(genthei•uiaf closed loop)•'i".• ,,.
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UiC,County,State,Variance,etc.) ft. ft. i in.
3.Well Use(check well use): ft. ft. I in.
Water Supply Well: 17.SCREEN <. ' 'f , . ',•, i .f-' • "
FROM TO DIAMETER . SLOT SIZE THICKNESS MATERIAL
*'Agricultural DMunicipal/Public ft. ft. in. I
*"Geothermal(Heating/Cooling Supply) EC Residential Water Supply(single) ft. ft. in.
NI Industrial/Commercial DIResidential Water Supply(shared) 18 GROOT
•
"Irrigation FROM , TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it 20 ft- Bentonite ! Pumped
•
it Monitoring DRecovery ft. ft. Cap Top with Bentomite chips
Injection Well:
ft. ft.
M1:"Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK ifa applicable)pP ) .. - ..
*I Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD _P.
it Aquifer Test QIStormwater Drainage ft. ft.
*,Experimental Technology OSubsidence Control ft. ft.
' I Geothermal(Closed Loop) OTracer 20:DRILLING LOG(attach additional Sheets if necessary)-.'t.z,
.
FROM .TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) ,Other(explain under#2I Remarks)
o ft• 90 ft• OVER BURDEN
4.Date Well(s)Completed: 10/06/2023 Well ID# 90 ft* 485 ft• GRANITE .
-5a.Well Location: ft. ft. ' >`-'t ri--,e t
Hubert King/Dennis Payton ft. ft. . '>�'`a,.--",i-:, � %;v'q
Facility/Owner Name Facility lD#(if applicable) ft. ft •
NO I/
0 Terrapin Trl., Hendersonville, 28731 ft. ft. 1, iV V 2023
Physical Address,City,and Zip ft. ft I 11 t' a t^ pr
Henderson 9598606125 ,,2t:$R'EniAIMS." . :-• "f : • •` . : _• _ 0,4 -0 1 ` • r
County Parcel Identification No.(PIN) this 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:
N "' ` 1Oil 1/2023
0 6.Is(are)the wells) Permanent or i Temporary Siena a of Ce edontraclor ? Date
By signing th form,I hereby certify that the well(s)was(were)constructed in accordance
7.is this a repair to an existing well: DYes or EINo with ISA NCAC 02C.0100 or 15A NCAG'02C.0200 Well Construction Standards and that a
If this is a repair,fill out known 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 of 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 pageI`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 1•
9.Total well depth below land surface: 485 (ft) 24a. For All Wells: Submit this',form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@I00') construction to the following: I.
10.Static water level below topof casing: 35
g� (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 '
(i.e.auger,rotary,cable,direct push,etc.) li
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: •
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 8 Method of test: RIG 24c.For Water Supply&Iniectt'on 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: 20 completion of well construction to tli a county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources" i Revised 2-22-2016
I