GW1--01373_Well Construction - GW1_20240304

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kevin White 14.WATER ZONES= d =
FROM TO DESCRIPTION
Well Contractor Name 20 i' 25 ft• I Wet
2973A ft. ft. 1 ;
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft 15 ft• 2 in• sch40 PVC
List all applicable well permits(i.e.Counry,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER ' SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft. 25 ft 2 in. 010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
- OIrrigation----- - - --------- - _- - - -- 1- --ft- 3- • -fr- Bentohite'Chii-Tremie- -__-
Non-Water Supply Well: rt. ft. Tremie
❑O Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVELPACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery ❑Salinity Barrier 3 ft. 25 ft' #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary).
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft ft.
1/23/24 M P-I R ft. ft. '
4.Date Well(4)Completed: Well ID# ft. ft. P""" '' 'TM -r..,-,.
5a.Well Location: ft. , ft m t V L.Li
Waste Management, Inc. Henderson County C&D Landfill ft ft. MAR 0 it 2024
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
802 Stoney Mountain Road, Hendersonville 28791 ft ft °,'' '"`'' 3-- . : tjl4 5
Physical Address,City,and Zip - '
21.REMARKS
Henderson 2 x 2 Pad and 4"Cover
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)
35.352111 -_ N -82.497101 W. CO Of&-- o� •a (•p)
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,/hereby cern&that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: DYes or ONo 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
repair under 421 remarks section or on the back of this form. 23.Site diagram-or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 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
9.Total well depth below land surface: 25 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-9@200'and 2@100') construction to the following:
10.Static water level below top of casing 20 (ft.) Division of Water Resl urces,Information Processing Unit,
If water level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy off this form within 30 days of completion of well
HSA & 2" spoons
12.Well construction method: construction to the following: i
(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
24c,For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
Also submit one copy of this fonm'within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013