GW1--07547_Well Construction - GW1_20231121

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers 14.WATERzoNEs�. w; I
Well Contractor Name FROM TO DESCRIPTION I
4471-A ft. ft
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASINN(for multi-eased wells)OR LINER(if*Iteable) `_ , ,
CLYDE SAWYERS &SON WELL&PUMP INC FROM TO DIAMETER' THICKNESS MATERIAL
+1 ft 83 ft. 6.25 In• #21 PVC
Company Name !
OSS-2023-0957 16.INNER CASING OR TURING(geothermal closed loop)'- -
2.Well Construction Permit#: FROM TO 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): H. ft. in.
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in. '
Industrial/Commercial DIResidential Water Supply(shared) IB.:GROUT. .F `
.
`Irrigation FROM TO MATERIAL'I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 I't. 20 ft• Bentonite + Pumped
Monitoring Recovery ft. ft. Cap Top with Bentemite chips
Injection Well: ft. ft.
Aquifer Recharge 0 Groundwater Remediation 19.'SANDlGRAVEL PACK(if applicable)•'
Aquifer Storage and Recovery OISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OlStormwater Drainage ft. ft.
Experimental Technology 0ISubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer '20.DRILLINGLOG(attach additional:sheets if necessary)< _ ',.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 ft. 83 ft. OVER BURDEN
4.Date Well(s)Completed:09/26/2023 Well ID# 83 ft. 188 ft.. GRANITE !.T
Sa.Well Location: ft. ft. ,. `r e,,, .`
Paul &Jacqueline Witt ft. ft. NO V 2
2023
Facility/Owner Name Facility ID#(if applicable) ft. ft.
88 JP Huggins Drive., Hendersonville, 28791 ft. rt. in''..-,'::" .'7n ?:-- .
Physical Address,City,and Zip ft. rt. �'",°v'-'L%•"i`
Henderson 9650840355 21.REMARKS'
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: 1
N `� �` _ 09/28/2023
6.Is(are)the well(s) Permanent or Temporary Signs a ofCei edontractor Date
I
By signing th.form,I hereby cert(ty that the well(s)was(were)constructed in accordance
7.is this a repair to an existing well: DIYes or EIINo with ISA NCAC 02C.0100 or 15A NCAC 03C.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 ire/l owner.
repair under#11 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS I
9.Total well depth below land surface: (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 1@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: constriction to the following: I I
(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
13a.Yield(gpm) 30 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: 35 completion of well construction to the county health department of the county
where constructed. `I
Form GW-1 'North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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