GW1--07557_Well Construction - GW1_20231121

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers /f4 wATEwzoN _ ,Yi -
•
Well Contractor Name FROM TO DESCRIPTION I
ft. ft.
4471-A
ft. ft.
NC Well Contractor Certification Number
iS,mOUTERECA$tNG'(far multitared,welly"OR LINER(if a) icable)' :- ,.ro
CLYDE SAWYERS &SON WELL& PUMP INC FROM TO DIAMETERI ' THICKNESS MATERIAL
+1 rt• 110 ft' 6.25 l'tn' #21 PVC n-,y
Company Name
OSS-2023-1078 .16.INNERdASING'QR3'UBING;(eotlertnatclosed164p.' .
2.Well Construction Permit#: FROM TO DIAMETER 1 THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State.Variance,etc.) ft. ft. n.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17..SCREEN._,`:, ,': .WII' � _x_. .. 4;' .a - ..
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ji Agricultural DMunicipal/Public ft ft. in.
II Geothermal(Heating/Cooling Supply) EgResidential Water Supply(single) ft. ft. in.
II Industrial/Commercial DResidential Water Supply(shared) 18 GROUTs-.. l,.> -4, ,,t ':
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft• 20 ft• Bentonite ' Pumped
aiMOriitoring Elzecovery ft. ft. Cap Top with Bentomite chips
f
Injection Well: ft ft ;
*Aquifer Recharge 0Groundwater Remediation
19:RAN'D/GRA EJ.PACK'(ifapplie6l b) ...,... , .`s ..,.. ,, ._.>. :4`
ItAquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
*Aquifer Test QStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft. i'
[Geothermal(Closed Loop) OTracer 20.1DR1LLING.i OG(atthcl%additid110I&poets if necessary ,,I ...•.
FROM TO DESCRIPTION(color,hardness,sod/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft. 110 ft• OVERBURDEN
4.Date Well(s)Completed: 10/16/2023 Well ID# 110 ft• 405 ft' GRANITE .
5a.Well Location: R. ft. + , _a, si a'
Cody Hendson ft. ft. i cility/Owner Name Facility lD#(if applicable) ft. ft. I' f NOVl ��23
255 Woodrow Way, Hendersonville,28792 ft. ft. h
Physical Address,City,and Zip ft. ft. �;-;b i�(t0i
Henderson 10010836 -- 1 EMA s w .* it . d,., yi, , ,2,
County Parcel Identification No.(PIN) _this well was self l.ertified
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N "' 10/19/2023
6.Is(are)the well(s) Permanent or oI Temporary Signa a offer ed ontractor Date
By signing th.firm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: i Yes or EiNo with 15A NCAC 02C.0100 or 15A NCAC 02C.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 beets provided to the!veil owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.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. You may also attach additional pages if necessary.
drilled:' SUBMITTAL'INSTRUCTIONS
9.Total well depth below land surface: 405 (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:35 (ft.) +
Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Centelr,,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells: In additioti 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: h
(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) 4 Method of test: RIG 24c.For Water Supply&Injection!Wells: In addition to sending the form to
the address(es) above, also submit o e copy of this form within 30 days of
13b.Disinfection type: PILLS Amount: 20 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016