GW1--01163_Well Construction - GW1_20240219

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers a4AVATERIONEMWO ''' ',War . x M - w- , ;'g:.l'l
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
ft. ft. I i
NC Well Contractor Certification Number IS`()t3;1"ER.CASiiYi'i{furrnlii a rseil4C114)URa1zIPfERtltFtp tesbie)r . `• ' 'n
CLYDE SAWYERS &SON WELL&PUMP INC FROM 'ro DIAMErRR THICKNESS MAATERIAI.
+1 ft 54 ft' 6.25 , rn #21 PVC
Company Name .1G1NNER:G'A
OSS-2023-1623 CA
S)NGOR;T[tB1NGs{gct4bern'iulclosc4loop cam€ V . :'
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:
b
FROM TO DI
Agricultural SIZE THICKNESS MATERIALAgricultural O1\4unicipal/Public ft. H. in.
Geothermal(Heating/Cooling Supply) 13 Residential Water Supply(single)industrial/Commercial
Irrigation
Non-Water Supply Well:
ft. ft. in.
Residential Water Supply(shared) tB GRUUT fir:', Wit.= ; OWF4,,; , rca� ,,,
...... FROM TO MA'1'F.R1.41. F;MPLACEM ENT METHOD&AI110UN'I'
o ft 20 it Bentonite Pumped
Monitoringell:
Recovery ft. ft. I Cap lop with Bentomite chips
Injection W
ft. ft-
Aquifer Recharge Groundwater Remediation
19:SAN1/GRA FT,.PAGIC(f apPllcatilr} -' ,r r .M s -�
Aquifer Storage and Recovery
Aquifer Test
El Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Drainage ft ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) ®Tracer20 DItI>I INGkT gt`: tlaeh'addtnbnalsheGfs ifnecessnri} V4
O
Geothermal(Heating/Cooling Return) ®Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size etc.)
0 ft. 54 ft• OVER BURDEN
1-23-2024 ft. ft. a `'sr-i. i D
4.Date Well(s)Completed: Well ID# 54465 GRANITE �r- - & H 0 E it
Sa.Well Location: ft. ft.Home Crafters ft. ft. F Eti i 9 2024
Facility/Owner Name Facility ID#(if applicable) ft. ft. hl�t� .^�L7 r^.�` rJ Eil°i�
20 Pioneer Lane Hendersonville, NC 28792 ft. ft. D�rQ; Jt
Physical Address,City,and Zip ft. ft.
Henderson 300661 120.Rt 1.Aitirsl` .` "-' Mte
County Parcel Identification No.(PiN) Well was self certified
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one hit/long is sufficient) 22.Certification:
i ,
N W 11-25-2024
6-ls(are)the well(s)>�X Permanent or MI Temporary Signa e of er edlh onhador Dale
By signing dt Orin,I hereby certij•t)mt the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or �xoNo with 15A JVCAC t)2C.0101)at 15A NVCAC 02C.0200 Well Construction Standards and that a
If this is a repair.fill out known well construction it formation and explain the nature of-the cops of this record has been provided to the well owner.
repair unn/er#l1 remarks section or on the back if 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: 465 (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?trl00) construction to the following:
10.Static water level below top of casing: 80 (ft.) Division of Water Resources,information Processing Unit,
I/water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells: in addition to sending the form to the address in 24a
ROTARY above,also submit one copy of this Iform 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,Uriderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) 3 Method of test: RIG 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit lone copy of this form within 30 days of
L3b.Disinfection type: PILLS Amount: 35 completion of well construction tlo the county health department of the county
where constructed.
,
Form(1W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016