GW1--05618_Well Construction - GW1_20240916

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information: I.
Kolby Mitchel Sawyers i€4.4IANATER=z0 's �Vr s�0,w ,.0A
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A ft ft.
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NC Well Contractor Certification Number "15«W:Mtt:MIts10(fOr`tnuln4ase�U 111:rtil2t' iNgittlt' p tcable) `I rW
CLYDE SAWYERS & SON WELL & PUMP INC FROM TO DIAMETER, • THICKNESS MATERIAL
+1 ft• 68 ft• 61/8 i;in' #188 STEEL
Company Name
OSS-2024-0631 itsaottl oi§iN owm e taiiiiirx iiiiiireiiii ;.
2.Well Construction Permit#: FROM TO DIAMETER: THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stare.Variance,etc.) ft. ft. I in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
t7if5CI EEIu T4a. A I ��`" gf ..,,,•.;:u
FROM TO DIAMETER ' SLOT SIZE THICKNESS MATERIAL
Agricultural EMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single)industrial/Commercial
Non-Water Supply Well:
ft. ft. in.
Residential Water Supply(shared) 18G[ZUT Fm t � � x
irrigation FROM TO MATERIALE:MPI,ACEME:NT METHOD&AMOUNT'
0 ft. 20 ft• Bentonite Pumped
Monitoring
Injection Well:
Recovery ft. ft. Cap Top with Bentomite chips
ft. ft
Aquifer Recharge Groundwater Remediation
SANE/Gfagt kACK-iniili06I} ' , i SIT ..*. ..AV
Aquifer Storage and Recovery ®Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test D Stonnwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
(Geothermal(Closed Loop) 13Tracer 241 1RILI G;Lt1F {ariikb7additiu al ae s if<necessatf , w„,a' '/
FROM TO DESCRIPTION(color,hardness,soil/rock type,gram size,etc.)
()Geothermal(Heating/Cooling Return) 1'Other(explain under#21 Remarks) 0 ft. 68 ft. OVER BURDEN
4.Date Well(s)Completed:8-16-2024 Well ID# 68 ft, 745 ft• GRANITE
5a.Well Location: ft. ft.
JOHNNY SHERMAN ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. i
1498 BRIGHTWATER DR HENDERSONVILLE, NC 28792 ft. ft. ,
Physical Address,City,and Zip ft. ft.
HENDERSON 954906236 araiEKOWS. x:,;=,„ ` Via'
County Parcel IdentiticationNo.(PEN) \FI I WAS SF! F CFRTIFIFF)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one Iat/long is sufficient) 22.Certification:
cAfralle
N W _ 8-30-2024
6.Is(are)the well(s) Permanent or Temporary Signs e of er ed� ontraclor Date
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By signing th brat,I hereby certij'tltat'the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: :Yes or E3 No with 15A IVCAC 02C.0100 or 15A NCAC(12C.0200 Well Const)oftStande1rds and that a
If this is a repair..fill out known well construction information and explain the nature of the col,of this record has been provided to the well owner. 't i. it Kv r'1% f.':—,-
repair under el remarks section or on the back of this form. '- if q p
23.Site diagram or additional well details: ((++��-n/� a ,
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional woli"siie lets c5}wgp
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pagifies if necessary. CC CL4
drilled: 1 "..kvc l?rr,.,.
SUBMITTAL INSTRUCTIONS �, S/Ay,°;;�•1,
745 +`t�, .�a,(;l, .% h$
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdilferen:(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Centeir,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) 30 Method of test: RIG 24c.For Water Supply&Injection I 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: 35 completion of well construction to the county health department of the county
where constructed.
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Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016
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