GW1--07548_Well Construction - GW1_20231121

WELL CONSTRUCTION RECORD For Internal Use ONLY: I'
This form can be used for single or multiple wells
1.Well Contractor Information:
Ili ATERIzONE... , ....
Derrick Heath Sawyers _FROM TO DESCRIPTION
Well Contractor Name ft. ft. I i
2436-A ft. ft. i I
NC Well Contractor Certification Number 15ISODTEICGASi0l G jft ai tilil used i i`}:OIM NE (ifcap jIcaiite}5 ,
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 52 ft- 6.25 On. #21 Pvc
Tkf0t6IEI NSiWOft.VU,13ING11a'et,'EbraiPe gsed i4up)
Company Name
OSS-2023-1118 FROM TO DIAMETER THICKNESS MATERIAL2.Well Construction Permit#: ft. ft. 1 in.
List all applicable well permits(i.e.County,State,Variance,lnjection,etc.) ft. ft. i in.
3.Well Use(check well use): WIVSGREEN l sa ,
Water Supply Well: FROM TO DIAMETER ..SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) E lResidential Water Supply(single) ft. ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) fR G126U3 � � � "
FROM TO MATERIAL EMPLACEMENT MF.TAOI)&AMOUNT
❑irrigation 0 ft* 52 ft• Bentonite Pumped
Non-Water Supply Well:
ft. ft. Cap Top with Bentonite Chips
❑Monitoring :Recovery l
Injection Well: it. ft.
❑Aquifer Recharge ❑Groundwater Remediation ` 9:5✓A7 D/GTtili'•uE'C:PACIOVI tfpti't th e#` r '''
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft. i
:Aquifer Test ❑Stormwater Drainage
it. ft.
❑Experimental Technology ❑Subsidence Control 2U i)1T1 24010- taltk ifildilifi n Iitteefs itinecesseta `"'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color•hardness,soil/rock type,grain size.etc.)
❑Geothermal(Heating/Cooling Return) :Other(explain under#21 Remarks) 0 ft. 52 ft. 11 OVER BURDEN
9-19-2023 52 ft. 205 ft• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft.
DIXIE CARD ft. fr4.1` i,� q
Facility/Owner Name Facility ID#(if applicable) • L .c t�.,,.n Ft, t! R_.,;'
ft. ft.
71 HARVEY OSTEEN ROAD HENDERSONVILLE, NC ft. ft. NOV A 2023
Physical Address,City,and Zip 211 RTtNlARI S ->� ,Ta'AN,. -,. „,
HENDERSONVILLE 9565286078 "' "
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 `It 9-20-2023
Signatuor.,...5
ertified Well Contract° I Date
6.T5(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 1SA NCAC 02C.0100 nr 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo 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 I
repair under#21 remarla•section or on the back of this.forni. 23.Site diagram or additional well details:
You may use the back of this page Ito 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 1.
9.Total well depth below land surface: 205 (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 1 00'and 2(1000) construction to the following:
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"+" 1617 Mail Service C i nter,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
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ROTARY construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,iUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
20 RIG 24c.For Water Supply&Injectio I Wells:
13a.Yield(gpm) Method of test:
PILLS Also submit one copy of this fonn within 30 days of completion of
13b.Disinfection type: Amount: 20 well construction to the county health department of the county where
constructed.
1
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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