GW1--07544_Well Construction - GW1_20231121

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells -
1.Well Contractor Information: 1
Derrick Heath Sawyers FROM TO DESCRIPTION
Well Contractor Name ft. ft. I j
2436-A ft. - ft. I 1
15u
NC Well Contractor Certification Number f/lITERVASING it i iuIB'easseit iOi s t)Rc1 INtftl(ifit i Will"iej� % ''..
FROM TO DIAMETER' I THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 52 ft. 6.25 rin' #21 PVC
Company Name is 1NNERYGASING.t7it?Fl1BI G1(ao'lblPniat cliisetl=lfoo > 5
OSS-2022-0486 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. i in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): tj:7 SCRCEN.: " .,' 1 ..•l ;
Water Supply Well: FROM TO DIAMETER i SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ©Residential WaterSupply(single) tt. ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) :tR'GR(lU, ' '''-W,,,,,'. ''l s i',; Ns0`0,
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lmgation 0 ft• 20 ft• Bentonite Pumped
Non-Water Supply Well:
❑Monitoring DRecovery ft. ft. Cap Top with Bentonite Chips
injection Well: ft. ft.
DAquifer Recharge ❑GroundwaterRemediation ,%1nSAN11/GRtri"yL`I PAVIC(it.appIIca(Te)` = .- 1`...1
FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft. 1
❑Aquifer Test ❑Stormwater Drainage - ,
ft. ft. 1
❑Experimental Technology ❑Subsidence Control xi=
ZOb1tlGt:tNGIE(lG tatiacl addrti4at_kh"`4ts itmcessarv)AWURWi - ,w:
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft• 52 ft- ! OVER BURDEN
11-13-2023 52 ft• 365 •ft, I GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft. � _
5a.Well Location: ft. ft. " r
Maureen Gough ft. ft. tr.`•` ~
Facility/Owner Name Facility ID#(if applicable) ft. ft. NO V g ( 2023
330 Trelleum Trail Hendersonville, NC 28792 -
ft. ft. In,.,,
Physical Address,City,and Zip 2t;1iRH'NTAftta. u? ' v ""=s " 5 --` 1+
Henderson 9547304555 Well was'Self Cetified -'
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) I
11-15-2023
N w e o
Signature citified Well Coutracto Date
6.is(are)the well(s): OPermanent or ❑Temporary i
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
• with ISA NCAC.02C.0100 or 15,4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes nr EINo copy of this record has been provided to the well owner.
If this is a repair.fell out known well construction information and explain the nature of the I
repair under#21 remarks.section or on the hack of thisJorm. 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: 1 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 i
submit one form. SUBMITTAL INSTUCTIONS
1
9.Total well depth below land surface: 365 (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 dt 00'and 2(a�100') construction to the following: i
10.Static water level below top of casing: 50 (ft.) Division of Water Resources',Information Processing Unit,
If sinter level is above casing.use"+" 1617 Mail Service Center,,Raleigh,NC 27699-1617
11.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: l
(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 Centi r,IRaleigh,NC 27699-1636
13a.Yield(gpm) 0 Method of test: RIG 24c.For Water Supply&Injection Wells:
1Also submit one copy of this form vnthin 30 days of completion of
PILLS
13b.Disinfection type: Amount: 35 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