GW1--05616_Well Construction - GW1_20240916

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: 1 ,
Kolby Mitchel Sawyers
_FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
ft ft. t
NC Well Contractor Certification Number 15.Ol3TER OXStbi fit° ut iesei iVii1il13ii IPit12it3I p If iilitOV v
CLYDE SAWYERS & SON WELL & PUMP INC FROM TO 11IAMEIER THICKNESS MATERIAL
+1 ft. 33 ft. 6.25 l•in. #21 PVC
Company Name
OSS-2023-1008 i moist igrl cOpoc rlvari itl,traweicgaoti :... vL 'Al
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. ' in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
h
FRODf TO DIAMETER SLOT SIZE THICKNESS MATERIAL
AgriculturalMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) Ea Residential Water Supply(single)industrial/Commercial
Non-Water Supply Well:
ft. ft. in.
®Residential Water Supply(shared)
irrigation FROM TO \ sIATitrn AI, IiMPI,ACEMENTMETHOD&AMOUNT'
0 ft. 20 ft- Bentonite. Pumped
Monitoring
Injection Well: DRecovety ft. ft: Top with Bentomite chips
ft. ft.
Aquifer Recharge Groundwater Remediation
£I9ai1N,4BANII` CCI WaIiaf lr)x A . .. W. •• .` ``
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIALEMPLACEMENT METHOD
Aquifer Test �Stonnwater Drainage ft ft. i,
Experimental Technology Subsidence Control ft. ft.
riIGeothermal(Closed Loop) 0Tracer 2ii)L1Rl h tti tail'fiif aidaitia is s`ice ifxheeaiiiS)% slOgAPAt
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) ®Other(explain under#2I Remarks) 0 ft. 33 ft. OVER BURDEN
•
4.Date Well(s)Completed:8-2-2024 Well ID# 33 fL 125 ff• GRANITE
ft. ft.
5a.Well Location:
BRIAN&KRISTEN SULLIVAN ft. ft. '
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
AWENASA HILLS HENDERSONVILLE, NC 28792 ft. ft. •
Physical Address,City,and Zip ft. ft.
HENDERSON 9547206676 f 1 AR 2:: - "26,0.
County Parcel identification No.(PIN) ppFI I WAS SFI F CFRTIFIFD
• 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: i
1
N W 8-5-2024
6.Is(are)the well(s)O% Permanent or Temporary Signa e offer ed onhactor Date
By signing th bran,I hereby certifj'that Ihe well(s)rim (were Dnstrtected_' •groan e
7.Is this a repair to an existing well: Yes or x No - with 15,4:VCAC 02C.0100 or 15A rVCAC 02C'.t)2t)0 Well Con t uciior Sunda�aa, Oa . '
If this is a repair.fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner. tl !} 1
repair under#2I remarks section or on the back of this form. g S E P 1 i� 204
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 we 1
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional plit �chelss�ry,�rr t
F:`r. rrc :.• : .4rt4t..1 1.n si
drilled: ' SUBMITTAL INSTRUCTIONS �+�'Cs s
1.
9.Total well depth below land surface: 125 (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 a,10(l) construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources;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.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
13a.Yield(gpm) 30 Method of test: RIG 24c.For Water Supply&Injection 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 OW-1 North Carolina Department of Environmental Quality-Division of Water Resources , Revised 2-22-2016