GW1--02964_Well Construction - GW1_20240513

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Ptah Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
1.Well Contractor Information: 1
Kolby Mitchel Sawyers ra:«miRZONc"sn. : �;rmaww .. v mgf m
FROM TO DESCRIPTION
Well Contractor Name ft. ft. ` I
4471-A
ft. ft. I,
NC Well Contractor Certification Number vs15 Ul7TE1{CASING"(ftir,'routtt.easiil;vel[s)-t7R>I1NERr(if a[s`tieatit¢) `"`".RA '+
CLYDE SAWYERS &SON WELL &PUMP INC FROM TO DIAMETER . THICKNESS M.ATERIAI.
+1 ft' 58 ft' 6.25 in* #21 PVC
Company Name
OSS-2023-1371 16.�i�vriER,casirrGclRTuurNc'(;t�ihCrmal:ii�ea=ra` �;�, . M �
,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. I in.
3.Well Use(check well use): ft. ft. in.
EWater Supply Well: 1I,ISCRREI'11 ?< .,ri ' s `" s <'+s">.:;�.s.,``z'; ' .' .Ft ', . 'M.Al
pp FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public ft. ft. in
Geothermal(Heating/Cooling Supply) E3Residential Water Supply(single)industrial/Commercial irrigation
Non-Water Supply Well:
ft. ft. in.
Residential Water Supply(shared) t18."GRt)tfTx7, o� ,., .r,> _ �� n .,'r • ,,s• .
mom TO al A'1'ER1.41. EMPLACEMENT METHOD&AMOUNT
0 ft. 20 ft. Bentonite Pumped
Monitoring
Injection Well:
Recovery ft. ft• Cap Top with Bentomite chips
ft. ft.
Aquifer Recharge Groundwater Remediation
�9.SAA'tgAtAVEL AtK(af ap`pliaa ile) "�� a u . .<H:`^ref�;`
Aquifer Storage and Recovery ®Salinity Barrier FROM To MATERIAL EMPLACEMENT METHODAquifer Test �Stonnwater Drainage ft. fr.
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) °Tracer 32U.rDE1Ti`1LNG4 t3G taifach addttionii:sheets ifinecessa`ry3' -'.''3' 'c�Wi
Geothermal(Heating/Cooling Return) riOtber(explain under#21 Remarks)O
FROM' TO DESCRIPTION(color-hardnes soil/rock type.grain size,etc.)
0 ft. 58 ft. OVER BURDEN
4.Date Well(s)Completed:.2-8-2024 Well ID# 58 ft- 365 ft- GRANITE
Sa.Well Location: .t 4 v.,L. L.i 31 1—. .1.T
•
CODY HENSON ft. ft. i'
Facility/Owner Name Facility ID#(if applicable)
ft. ft. J. MAY 1 = 2024
24 HOLLIFIED DRIVE HENDERSONVILLE, NC 28792 ft. ft. Ir FI.1.1 �,<P. ':s741•^1.":» i?.,j Ufr?d
Physical Address,City,and Zip fL ft. t r�G(%9C7
HENDERSON 9598514032 2I i1tEZIdIFIsi( y ', „'3 f!,,, , . e rr! ` M ;'" , 4
County Parcel identification No.(PiN) 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
2-9-2024
6.Is(are)the well(s) Permanent or Temporary Sigma a of er ed ontiactor Date
x
By signing th form,I hereby cm.*that the well(,)was(here)constructed in ace•or•dam e
7.Is this a repair to an existing well: DYes or %®INo with 15.4:VCAC 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 stature of the copy of this record has been provided to the sell owner.
repair under#21 remarks section or on the back of this form.
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. You may also attach additional pages if necessary.
drilled:1 SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: 365 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welts list all depths if different(example-3@200'and 2@100) construction to the following: I ,
I :
10.Static water level below top of casing: 60 (ft.) Division of Water Resoti'rces,information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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 '
(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
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 one copy of this form within 30 days of
13b.Disinfection type: PILLS Amount: 35 completion of well construction to the 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