GW1--07546_Well Construction - GW1_20231121

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
!Kolb Mitchel Sawyers °14a4ATERLON�S
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Well Contractor Name FROM _ TO DESCRIPTION
4471-A ft. ft.
ft. ft. I
NC Well Contractor Certification Number
1Sr'OCJTER CASING(for multi-raced wellj AR"LINER(if ap )ieable)� , ,
CLYDE SAWYERS&SON WELL& PUMP INC FROMTO DIAMETER ' THICKNESS MATERIAL
+1 ft. 48 ft. 6.25 i in: #21 J PVC
Company Name
OSS-2023-0918 ''.16.INNER CASING OR TUBING(geothermal cased-loop) -
2.Well Construction Permit#: FROMTO DIAMETER` THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance.etc.) ft. ft. 'in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN�,r•,!., - _` Y-. =' _
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural DMunicipaUPublic ft. ft. in. ••
Geothermal(Heating/Cooling Supply) EllResidential Water Supply(single) ft. ft. in, ;
O Industrial/Commercial QResidential Water Supply(shared) SBE,GROUT, . -' _.;,, -.. n
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft. Bentonite Pumped
OMonitoring EDRecovery ft. ft. Cap Top with Bentomite chips
Injection Well: • R. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL,PACK(if applicable) - ' ";,a'4'
Aquifer Storage and Recovery
Aquifer Test
Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
�IStormwater Drainage R. it
Technology ®ISubsidence Control ft. ft.
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Geothermal(Closed Loop) Tracer '20.'DRILLINGI OG.(attacb additional sheets'if necessary)°'<. .
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,solurock type.grain size,etc.)
0 ft* 48 fL OVER BURDEN
4.Date Well(s)Completed:09/21/2023 Well ID# 46 ft• 245 ft• GRANITE
5a.Well Location: ft. ft.
Johnny Sherman ft. ft. '�Y, -« 'r''
Facility/Owner Name Facility 1D#(if applicable) ft. . ft. I N )V 2 1
11 Canary Ln, Hendersonville,28792 ft. ft.
2023
Physical Address,City,and Zip ft. ft. 'I I'"'.-G;=z'::it el),-.....__
'ri I t.-u
Henderson 0602437741 '21.REMARKS ".Y?-` _ ` ...,;.Y.-1. ''
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 W
09/25/2023
6.Is(are)the well(s) Permanent or Temporary Signa a of ed ontractor Date
By signing thin,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: lJYes or EgNo with ISA NCAC 02C.0100 or ISA NCAC OZC.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction in/brnration and explain the nature oldie copy of this record has been provided to the well owner.
repair under#21 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
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: 245 (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@100) construction to the following:
10.Static water level below top of casing:20 (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.) •
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) 12 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: 25 completion of well construction to the county health department of the county
where constructed.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources ! Revised 2-22-2016