GW1--07554_Well Construction - GW1_20231121

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers .,' alikiNWERIONE 'M ri
Well Contractor Name FROM TO DESCRIPTION I
ft. ft. I I
4471-A ft. ft.
NC Well Contractor Certification Number j ptjll hl{?'GpSI1SIG:(foi mnld eased svi;71`sNkEINEtt`it `ticabtij lEl ' '
CLYDE SAWYERS&SON WELL& PUMP INC piton! 'rO I)IAME PER II ' THICKNESS MATERAAI.
+1 ft. 56 ft• 6.25 P° #21 PVC
Company Name
OSS-2023-1092 143StrER ASINOt itrni G<t ilierntnteids%d=ro p e 'x
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): ft. ft. in.
Water Supply Well: 17i SCREEhi,. .> ,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
all Agricultural ®Municipal/Public ft. ft. in.
*IGeothermal(Heating/Cooling Supply) E3 Residential Water Supply(single) ft. ft. in.
all industrial/Commercial ®Residential Water Supply(shared) ,;18 GkO1.11' . ... .,'n,, ';=. „'. . ' .' '
`.. 'Irrigation
FHODI TO SIA'I'ERI.AL' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft, 20 ft' Bentonite I Pumped
NI Monitoring EIRecovery ft. ft. Cap Top with Bentomite chips
Injection Well:
ft. ft.
1 Aquifer Recharge D Groundwater Remediation
108A`NU/GRiI'UE VAtiOit filitieatit} rA s w x `; ',;
l Aquifer Storage and Recovecy 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
*Aquifer Test 13 Stonnwater Drainage ft. ft.
1'Experimental Technology 13 Subsidence Control ft. ft. i'
I
jN!Geothermal(Closed Loop) OTracer 2il:1bRIIyL1tVG'iEtlG.{aita¢>, ddihonarsheuts:rfiecessatji:., �;.,XWa'
FROM TO DESCRIPTION(color.hardness,soil/rock type.grain size,etc.)
(Geothermal(Heating/Cooling Return) EtOther(explain under#21 Remarks)
0 ft. 56 ft• OVER BURDEN
4.Date Well(s) 10-4-2023 Completed: Well iD# 56 ft' 765 ft' GRANITE r ,- ".T
5a.Well Location: ft. ft. b v i;_-
'f1__is tiv n '_..
Cody Henson ft. ft.ft. . ft. 12023
ND V
Facility/Owner Name Facility ID#(if applicable)
3300 SUGARLOAF MTN ROAD HENDERSONVILLE,NC 28792 ft. ft. Ini:,r7c:2...i^n ? J 1,11 i
Physical Address,City,and Zip ft. ft. ``°`v °'Wit`
HENDERSON 9966432 kzl:''ltEmARKs a. An . ''4:
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 10-4-2023
6.Is(are)the well(s) Permanent or DTemporary Signa e of er ed ontractor Date
%
6y signing dr bras,I hereby certifj'that the well(s)teas(were)constructed in accordance
7.Is this a repair to an existing well: DYes or 0No with 1SA,VCAC 02C.0100 or ISA NCAC(i2C.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:)'ell owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Ceoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page tojprovide additional well site details or well
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
I
9.Total well depth below land surface: 765 (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 @.,100) construction to the following: I
10.Static water level below top of casing: 160 (ft.) Division of Water Resources,Information Processing Unit,
I/'water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I
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 forrtl within 30 days of completion of well
12.Well construction method: construction to the following:
(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 Center;Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test: RIG 24c.For Water Supply&Injection W
ells: In addition to sending the form to
the address(es) above, also submit dt t: copy of this form within 30 days of
13b.Disinfection type: PILLS Amount: 35 completion of well construction to thle county health department of the county
where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources I ' Revised 2-22-2016