GW1--03513_Well Construction - GW1_20240612

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: _.
1.Well Contractor Information:
Kolby Mitchel Sawyers 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for and-cased wells)OR LINER(If AO Roble)
CLYDE SAWYERS & SON WELL & PUMP INC _FRoi To F DIAMETER THICKNESS MATERAAI. _
+1 ft. 55 ft. 6.25 in. #21 PVC
Company Name
OSS-2023-1 202 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,CountP,Slate,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DI.lMF I FR sI.OI .IZI' ' TIIIC K\I5S MATERI\l.
Agricultural ®Municipal/Public ft. ft. in.
°Geothermal(Heating/Cooling Supply) Q Residential Water Supply(single) ft. ft. in.
°industrial/Commercial °Residential Water Supply(shared) 18.GROUT _
°Irrigation PRUM T Mo \IrxI SI t.\IN S(I MI',I MI 1110111&nvut"i.I
Non-Water Supply Well: o ft. 20 ft. Bentonite Pumpcd
°Monitoring °Recovery ft. ft. Cap Top with Bentomite chips
Injection Well: ft. ft.
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK(if applicahl�
DI Aquifer Storage and Recovery °Salinity Barrier FROM TO NI\I ERIAI. EMPLACEMF S T Mr FIRM
Aquifer Test OStorntwater Drainage ft. ft.
DExperimental Technology ©Subsidence Control ft. ft.
°Geothermal(Closed Loop) °Tracer 2U.DRILLING;LOG(anaeh additional sheets if Recessary)
FROM TO DESCRIPTION(coin,hardness.soil/rock type.Quin size,etc.)
°Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) 0 ft 55 ft. OVER BURDEN
4.Date Well(s)Completed:4-1-2024 Well lD# 55 n• 165 ft GRANITE
5a.Well Location: ft ft. ._ +„•r< ii
BILLYS MODULAR& MOBILE ft. ft.
Facility/Owner Name i aeility ID#(if applicable) fL ft. JUN 1 2 2024
64 ALBERTO WAY HENDERSONVILLE,NC ft. ft.
Irrterti'4s i1 P'C2'Ws •t$Utt7F
Physical Address,City,and Zip ft. ft. d/ti 'lt es
HENDERSON 0602621341 21.REMARKS
County Parcel Identification No.(PIN) WF I I WAS SFI F CFRTIFIFD
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one tit Tong is sufficient) 22.Certification:
N W 4-5-2024
6.Is(are)the well(s)I Permanent or °Temporary Sig offer ed ontractor Date
By signing th arm,I hereby certify'that the well(s)was(mere)constructed in accordance
7.Is this a repair to an existing well: °Yes or Et No with 1.5.4 NCAAC 02C.I)10X)or 154 NCAC 02C'.0200 Well Construction Standards and that a
If this is a repair..ftll out known well construction information 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 back of this firm.
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 I 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: 165 (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@,loXY) construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,information Processing Unit,
II water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
It.Borehole diameter: 6•25 (in.) 24b. For Infection 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 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method of test: RIG' 24c.For Water Supply& Iniection 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: 20 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