GW1--07538_Well Construction - GW1_20231121

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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:
Kol by Mitchell Sawyers 14`wATEz°z"l s ' W
FROM TO _ DESCRIPTION
Well Contractor Name ft• ft.
4471-A ft. ft. I 1
NC Well Contractor Certification Number
:t5 OUTEfta�AgitYC:(viiiu1H cas6i)eftsyoftloI�TRlzsorhi'ite" 6tip -.
FROM TO DIAMETER THICKNESS MATERIAL.
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 88 ft• 6.25 Ii in. #21 PVC
Company Name eliN ro UBlIVCr,(i e0 hermut c ised=toad,, ,^�t�."INh1ER CASf1YlRrT
OSS-2023-1210 DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. ; is
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. ; in.
3.Well Use(check well use): fit,?VS('REEN; & .: "a. n m 0 WF ,,, 774a;
Water Supply Well: . FROM TO DIAMETER SLOT SIZE , THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑MunicipallPublic ,
OGeothermal(Heating/Cooling Supply) OResidential WaterSupply(single) ft. it. in.
18:GRUUT � s � MV '"4:,i ce "' �*''
❑IndustriaUCotnmercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT MF,TROL)&AMOUNT
❑l,Tigation 0 ft• 20 ft• Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft. Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑Aquifer Recharge 0 Groundwater Remediation ZIWSANIVOICAVAIMIGICrtitijiiiiielib140, VallrA` '!:- n
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage -
ft. ft. ,
❑Experimental Technology 0 Subsidence Control 20 ,,
1/RIGLTNG�I>OG.(alxacl sd"ditia"nalsltcefiitneiiiiii D «
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock ripe.grain size.etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 88 ft. OVER BURDEN
9-21-2023 88 ft• 165 ft• I' GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft. I ---, --_
5a.Well Location: ft. ft. I, ''4,-,'
r " ') "'
BILLY'S MODULAR&MOBILE ft. ft. A'
Facility/Owner Name Facility ID#(if applicable) ft. ft. NO V 2 3. 2023
SAINT PAUL SUB LOT 3 HENDERSONVILLE, NC 28792 ft. ft. i "` -,,7„ ,^;'^� r�::-,,-. .;,,_ry l,f-r
Physical Address,City,and Zip 121MREMAIIKS ' t-s " st i' 's ,
HENDERSON 0602620187 WELL WAS SELF CERTIFIED
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 9-22-2023
Signature ofCertifi a Contractor Date
6.is(are)the well(s): OPermanent or OTemporary By signing this firm,1 hereby certify that(the well(s)was(were)constructed in accordance
with 15A 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(tuner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 1121 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
S.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 l'
9.Total well depth below land surface: 1 65 (ft.) 24a. For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths if different(example-4 dt 00'and 2(4)100) construction to the following:
30 Division of Water Resources,ces,Information Processing Unit,
10.Static water level below top of casing: (ft) t
If water level is above casing.use•'+" 1617 Mail Service Ceniter,Raleigh,NC 27699-1617
11.Borehole diameter: 6'25 (in.) 24b.For Infection Wells ONLY: hi 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.) 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) 12 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form iwithin 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
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