GW1--02965_Well Construction - GW1_20240513

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I Prin#Farm
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: +,
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• 1.Well Contractor Information:
P ,
Kolby Mitchel Sawyers 40wArEwzoiv>s " k-4 v : { i g °_ k,r w ". `/'
FROM TO DESCRIPTION
\\'ell Contractor Name ft. ft. I I
4471-A -
ft. ft. I i
NC Well Contractor Certification Number IK,OBTER•:GAASINtr(fo'r-multi.eas`eifivei[i)URIL11vER-titan liable): ` l2l °, i.
CLYDE SAWYERS&SON WELL & PUMP INC FROM '1'0 DIAMETER ' 'THICKNESS M.ArERIAI.
+1 ft 44 ft. 6.25 in" #21 PVC
Company Name
OSS-20024-0021 Yl•`'INNERcCASI$C ORTUBBINC(gcofhermal ctosed Ioop)z z +••.:c.v,
2.Well Construction Permit#: FROM TO • DIAMETER THICKNESS MATERIAL
List all applicable well coustntction permits(i.e.UIC,County,State,Variance,etc.) fL ft. In.
3.Well Use(check well use): ft. ft. in•
4-i Water Supply Well:
1{f:V"SGRTbIY"z ?.:.i, sax' a '.a t , ':2" ''°. n,a' ;;
FROM TOTHICKNESS MATERIAL
Agricultural �TA4urticipal/Public ft. ft. DIAMETER SLOT SIZE in.I
Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) fit. ft. in.
industrial/CommercialResidential Water Supply(shared) 18;GRUU fx,� rax ? ,n „� <s. f
irrigation FROM TO MA'I'RRl.At. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft. 20 ft. Bentonite Pumped
Monitoring Recovery fL ft. Cap Top with Bentomite chips
Injection Well:
fit. ft.
Aquifer Recharge ['Groundwater Remediation
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19 SANDIGRi1C EI;: .1CK'(if appin..lN)x' < z �.`
Aquifer Storage and Recovery Salinity Barrier FROSt TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStonnwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
PGeothermal(Closed Loop) ['Tracer l20_7)RIEL`1NGTSOG.tattacli'addraoa:ll'lsheetsiiiiiecesshiis 4 m'V1A1QMS.aig
FROM TO DESCRIPTION(cater,hardness,soil/rock type,grain size,etc.)
0Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks)
0 fit• 44 ft* OVER BURDEN
4.Date Well(s) 2-9-2024
Completed: Well ID# 44 fL 305 fit. GRANITE F. r�.,—.-,
Sa.Well Location: fL ft. l,'''�N.,...-N.,...-�_;, L,,i 1,7 1— i
AMANDA MOSS fL ft. MAY 2024
Facility/Owner Name Facility tD#(if applicable) ft. ft.
756 LANNING ROAD HENDERSONVILLE, NC 28792 fL ft. , lri`,vr I Z,.tfr-y.P�.• t''''s-4.,:.'. -WA
Physical Address,City,and Zip fL ft.
HENDERSON 10011758 420,RENARKsVIWW,',1AViawlaVgpMeggnallotAWRANAIWNZ.
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:
I
N N' 2-12-2024
6.ls(are)the well(s) Permanent or OTemporary Signs a of el ed ontnaclor Date
x
By signing di ornn,1 hereby certif.that the well(.)was(here)consn'ncted in accordance
7.Is this a repair to an existing well: 0 Yes or lNo with 15.4IVCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction it(fornarion and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the hack of this fo m.
23.Site diagram or additional well details:
R.For Ceoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the hack 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: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iifd cre,u(example-3@200'and 2 i100') construction to the following:
10.Static water level below top of casing: 80 (ft.) Division of Water Resources,information Processing Unit,
if water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
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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.e.auger,rotary,cable,direct push,etc.) •
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ien�ter,Raleigh,NC 27699-1636
13a.Yield(gpnr) 4 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: 30 completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016