GW1--07549_Well Construction - GW1_20231121

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: I'
Kolby Mitchel Sawyers asp TEIMWEs: q h.= a
R'ellContractorName FROM TO DESCRIPTION
ft. ft.
4471-A
ft. ft. I
NC Well Contractor Certification Number '`✓t5(3(1TEl2kelgltit fpr itiut(trcaseil weita"}bletl PIERiiei t4iat le) s`.
CLYDE SAWYERS&SON WELL &PUMP INC FROM TO DIANIKIER 1 THICKNESS MATERIAL
+1 ft• 65 ft• 6.25 I.in. #21 PVC
Company Name
OSS-2022-0637 16`=iNiNErcexstI`C.C►RT[tniNG(i cothcxtiint eloscd-toott ; <
2.Well Construction Permit#: FROM _ TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) -ft ft. t.in. .
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 017•SCRBEN a . .• . N,:
FROM TO DIAMETER .SLOT SIZE THICKNESS MATERIAL
$I Agriculture I Municipal/Public ft. ft. in.
al Geothermal(Heating/Cooling Supply) Ea Residential Water Supply(single) ft. ft. in.
�iindustrial/Commercial OResidential Water Supply(shared) MC GROUP ' M 'ice
iirrigation FROM TO MATF:RI.A It FM PLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 fr• Bentonite l' Pumped
MI Monitoring (Recovery ft. ft. Cap Top with Bentomile chips
Injection Well:
ft ft.
j 'Aquifer Recharge 0Groundwater Remediation •Ig SAND/t;RiT4t>ELIVAGIC(if ajppli4610 4`.
IIIIIIAquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL' EMPLACEMENT METHOD
IIAquifer Test DStonnwater Drainage ft. ft. 1`
Experimental Technology EiSubsidence Control ft. ft.
)NI Geothermal(Closed Loop) Tracer 20 D1211hIANCtsCltr(aiiaeli`liddingii tisheefrifsecoss`a"rj)'• 5
j♦IGeothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sin,etc.)
0 ft 65 ft• OVER BURDEN
4.Date Well(s)Completed:09/26/2023 Well ID# 65 ff• 245 ft.
pGRANITE
5a.Well Location: ft. ft. 4 '4. ,T I" _
Hearthstone Innovative homes ft. ft. (�' '
Facility/Owner Name Facility ID#(if applicable) ft. ft. NOV` W j �`'23
109 Richards Dr., Hendersonville, 28792 ft. ft. _ _
Physical Address,City,and Zip ft. ft. I r`ti %i te; ;_ rli a . t
Henderson 9661327075 011111trif., . .' " ;. �� '' '
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!at/long is sufficient) 22.Certification:
N • W
09/27/2023
6.Is(are)the well(s) Permanent or OTemporaty Sigma e of er ed onlruclor Dale
%
By signing tlr Orin,I hereby certijj'that the well(s)was(were)constructed in accordance
7.is this a repair to an existing well: ®Yes or. xoNo with 15A NCAC 02C.0100 or ISA NCAC(I2C.(1200 Well Construction Standards and that a
If this is a repair.Ill out known well construction information and explain the nature of the copy of this record has been provided to the;well owner.
repair under#21 remarks section or on the back of this form. I.
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-1 is needed. Indicate TOTAL NUMBER of wells construction details. Youmay also attach additional pages if necessary.
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drilled:' SUBMITTAL INSTRUCTIONS
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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 trolls list all depths if different(example-3@„200'and 2@I00') construction to the following:
10.Static water level below top of casing:20 (ft.) Division of Water Resourc ss,information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center;Raleigh,NC 27699-1617
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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 Cen per;Raleigh,NC 27699-1636
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13a.Yield(gpm) 15 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 thie county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016