GW1--04719_Well Construction - GW1_20240812

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers _ O14.WATER ZONES -
• PR \I IliDESCRIPTION
—�
Weil Contractor Name
4471-A ft. ft.
ft. ft.
NC Well Contractor Certification Number
ll'::u 'ltt l i(for multi-cased wells)OR LINER(if ap Ikable)
CLYDE SAWYERS& SON WELL& PUMP INC FROM '1'o DI XMIE1'E:R THICKNESS MATE:RIAI.
+1 fl. 5o t1. 6.25 in. #21 PVC
Company Name
22120113634 16.INNER CASING OR TUBING(gwt p)
2.Well Construction Permit#: FROM To ulA%IF IFR THICKNESS MAIERIAL
List all applicable bell construction permits tie.UIC,County.State. Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft. it. in,
Water Supply Well: 17.SCREEN
FR(l,\I 'CO DIAMETER SLO'1'ti1ZE: THICKNESS M&I1:R151
Agricultural ®Municipal/Public ft. tt. in.
Geothermal(Heating/Cooling Supply) ()Residential Water Supply(single)
PP Y( g ) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18•GROUT
Irrigation !to,1
ro 'SI rE.RLvt. Etl Pl,n('r�1PNr\Il rnoD&nm0(Nr
Nun-Water Supply Well: n ft. 20 ft. Bentonite Pumped
Monitoring ®Recovery -- ft. ft. Cap Top with Bentomile chips
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
O.SAND/GRAVEL PACK(if applicable)
\yuifer Storage and Recovery OSalinity Barrier MOM To n1 n ERfvI, EMI'I.,SCE?IENI ME:rutlD
Aquifer Test OStonnwater Drainage ft. ft.
BExperimental Technology ©Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer Geothermal(Heating/Cooling Return) 20.DRif LI1 G LOG(attach addition>yl sheets if necessary)
FROM TO DESCRIPTION BURDEN(cobra hardness.sot frock lyps,grain sire.etc.)
Other(explain under#21 Remarks) 0 ft. 50 ft. OV
4.Date Well(s)Completed:7-22-2024Well ID# 50 ft• 105 ft• GRANITE _ c a
5a.Well Location: fl. ft. t ti.�.�`z. 't f0
ARGYLE GASH ft. ft. v
Facility/Owner Name Facility ID#(if applicable)
ft. ft. AUG 1 2 2024
249 KUBOTA DRIVE HENDERSONVILLE,NC 28792 ft. ft. ,i _ ,r•.. .r,. :-4 ta:r
Physical Address,City,and Zip ft. It. fl cr• ``_
HENDERSON 951909231 21.REMARKS
County Parcel Identification No.(PIN) WFLI WAS SFI F CFRTIFIFf __ -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ---
(if well field,one Iatitong is sufficient) 22.Certification:
N " 7-23-2024
6.Is(are)the well(s)j% Permanent or DTemporary Signa a of C er ed onlractor o:ue
By signing th ornt,I hereby cerri/i'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: D Yes or No with I SA.VC'AC 112C.U!OO or ISA NC'AC(12('.0200 Well Construction Standards and that a
If this is a repair.fill out Anos,71 well construction information and explain the nature of the cope Otitis record has been provided to the well owner.
repair under#21 remarks section or on the hack r fthis Jinni.
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: ' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 105 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if di/let-ern(example-1(a)200'and 2(4,100') construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
If eater 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.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) 100 Method of test: RIG 24c.For Water Supply& Infection Wells: In addition to sending the form to
PILLS the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 20 completion of well construction to the county health department of the county
where constructed.
Form C;W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016