GW1--07543_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
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1.Well Contractor Information:
Derrick Heath Sawyers 14.'iS 1?Elt1 . , '' „ wok ,
FROM TO DESCRIPTION.
Well Contractor Name ft. ft. I I
2436-A ft. ft. II
NC Well Contractor Certification Number t5fft"ifttTt3RrtlStWG'(tO tiiuIti eat'eil t IrS}ttte:eftiEf2 iriMt eitft : '
FROM TO DIAMETER I I THICKNESS MATERIAL.
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 84 ft. 6.25 "• #21 PVC
Company Name
t .."i)yT C L r"SM t]<ft,Tt)lstl5lt tkaltt'r'inirei`s =t4 rug "'. .":i
OSS-2023-1649 FROM 'CO DIAMII'KHI 'THICKNESS MATERIAL .
2.Well Construction Permit ft: ft. ft. iin.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. iin.
3.Well Use(check well use): €l 5(121�^ , . ':' a ; '
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
1 ❑Agricultural :Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in. .
❑Industrial/Commercial :Residential Water Supply(shared) 1.5'GRDV ..v '" '�"' "° sue -
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hrigation 0 f' 20 ft. Bentonite,, Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft. Cap Top with Bentonite Chips
Injection Well: It. ft.
DAquifer Recharge 0 Groundwater Remediation 194SAEIRIGROEBPAGK:( ;uppllaftlea `. ``K F `
FROM TO MATERIAL' EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
j❑Aquifer Test 0 Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
28:IiR1W t'G taFt4ti uifiittioti t 6eetrifiteeessat vj s
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
I❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft, 84 ft. I, OVER BURDEN
11-14-2023 84 ft. 345 ft. GRANITE
4.Date Well(s)Completed: Well TD# ft. ft.
I ' f
5a.Well Location: ft. ft. I, z- `“ ''•\
MADONNA WALKER ft. ft. I' NOVacility/Owner Name Facility ID#(if applicable) N`J(J 2 1 2Q23
ft. ft.
359 SUGARLOAF MTN ROAD HENDERSONVILLE, NC 28792 It. ft. Ir:>C:i":;^ I ?r,; •, ,� ry l,r,
Physical Address,City,and Zip eittIVJAAkg.,AIR 'W „comma :.,' ��,,.. ,?
HENDERSON 0611501446 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 ,t 11-15-2023
Signature of citified Well Contracto,/ Date
6.Is(are)the well(s): (]Permanent or ❑Temporary By signing this form,1 hereby certify'that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or DNo 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 under#21 remarla•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: 345`� (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 gj 00'and 2@100) construction to the following:
Division of Water Resources;Information Processing Unit,
10.Static water level below top of casing: 50 (ft)
If water level is above casing.use"+'• 1617 Mail Service Center;Raleigh,NC 27699-1617
H.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY: 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,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636:Mail Service Center,'Raleigh,NC 27699-1636
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13a.Yield(gpm)2 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
PILLS
13b.Disinfection type: Amount: 32 well construction to the county health department of the county where
constructed.
Forte GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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