GW1--03518_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
Well Contractor Name FROM 10 DES('RIP1 ION
4471-A ft. ft.
ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
CLYDE SAWYERS&SON WELL&PUMP INC FROM 10 DIA\IL1 Lli IIDCKN I:SS M(I T:RI SI
+1 ft. 86 ft. 6.25 in. #21 PVC
Company Name
OSS-2022-0175 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: tR'1`1 I() mAMu.reR llu(KNrsc NIcel:Rl>I
List all applicable well construction permits(i.e.VIC,County,State, Variance,etc.) It. It. in.
3.Well Use(check well use): II. ft. In.
17.SCREEN
Water Supply Well: FROM •ro DI%MI t ER SLOT SIZE THICKNESS MATERIAL
[3 Agricultural 0Municipal/Public fL ft. in.
°Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. s in.
°Industrial/Commercial °Residential Water Supply(shared) Ix.GROLT
°Irrigation FROM TO MATERIAL EMI PLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. Bentonite Pumped
©Monitoring °Recovery ft. fL Cap Top with Bentomite chips
Injection Well:
ft. ft.
Aquifer Recharge E3Groundwater Remediation
19.SAND/GRAVEL PACE(if applicable)
°Aquifer Storage and Recovery °Salinity Barrier FROM TO MAT'ERLII. E?I PLACEMENT METHOD
[3 Aquifer Test °Storrnwater Drainage ft. ft.
°Experimental Technology °Subsidence Control ft. ft.
(3 Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.(
()Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) 0 ft 68 ft. OVER BURDEN
_
4.Date Well(s) 04-22-24 D#Completed: Well 1 68 rt- 805 ft• GRANITE
ft. ft. `'l _ i„,Y E D
Sa.Well Location:
�.u L.► f
AL WORLEY/WRIGHT It. It.
It IN 1 2 2024
Facility/Owner Name Facility ID#(if applicable) fL ft.
268 JUDSON RIDGE RD HENDERSONVILLE, NC ft. ft. r ti:ca t -r.rMIMKfill URiC
Physical Address.City,and Zip ft. ft.
HENDERSON 9622690648 21.REMARKS
County Parcel Identilication No.(PIN) THIS WFI I \AIAS SFLF-CFRTIFIFD
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W 03/05/2024
6.Is(are)the well(s)f% Permanent or °Temporary Signa a of .e ed ntractor Date
By.signing th orm,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or 1t°No with 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair.Jill 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 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: 805 (ft-) 24a. For All Welk: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:250 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1 I.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) 3 Method of test: RIG 24c.For Water Supply&Infection 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: 3o completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016