GW1--05619_Well Construction - GW1_20240916

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers SI4AVA=:l{ l s,: Y $' 7'WAVir,W . AaMM<
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
ft. ft. i 1
I
NC Well Contractor Certification Number 'r.��1VUt1:`GER.43AS1Nli'{fpry nUld tas d:'i ell4)OR*[i19ER'{ff:uW tleable} r 4
CLYDE SAWYERS & SON WELL & PUMP INC aRoo TO Pt:knit:It.R THICKNESS MAIERIAI.
+1 ft 38 ft. 61/4 l'1O #21 PVC
Company Name
OSS-2024-0813 I6 iNNER CA'Stl'G.i3RI'rUBING;(cuthcimalclosed=l6op") ` ;
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.
I
3.Well Use(check well use): ft. ft. in.
Water Supply Well: Sir/`:-aC12BiN # . x: :' ' ,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
AgriculturaI j Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) )a Residential Water Supply(single)
industrial/Commercial
ft, ft. in.
Residential Water Supply(shared) t8GRbEfTx � iarw � r� - ;
Irrigation
Non-Water Supply Well:
FROM TO ttlA 1'ERI.41. EMPLACEMENT METHOn&AMOUNT
0 ft. pp ft. Bentonite'. Pumped
Monitoring
•
Injection Well:
Recovery ft. ft. Cap Top with Bentomile chips
ft. ft.
Aquifer Recharge Groundwater Remediation
91SAND/C:I2ANEVIV CIC(ifz'applira to ` v'VRA ` 'WAWA
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHODAquifer Test EStomtwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
pGeothermal(Closed Loop) EjTracer 2lkIIRIEI3IIVU1 6G.t`a il"clf aazidirianatzheetsififeelssary) ' .:.
FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
Geothermal(Heating/Cooling Return) ®Other(explain under#21 Remarks) 0 ft. 38 ft. OVER BURDEN
4,Date Well(s)Completed:8-1 6-2024 Well ID# 38 ft. 805 it• GRANITE
ft. ft. 1.
Sa.Well Location:
JOHNNY SHERMAN ft. ft. I:
Feel I ity/Owner Name Facility ID#(if applicable) ft. ft.
1356 BRIGHTWATER DR HENDERSONVILLE, NC 28792 ft. ft. .
Physical Address,City,and Zip ft. ft.
i
HENDERSON :101R.EtulARtcs ., ' MK, >`
r
County Parcel Identification No.(PIN) WFLI WAS SFLF CFRTIFIFD
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N ," I 8-24-2024
6,Is(are)the well(s) Permanent or Temporary Signa a of er ed ontractor Date
IX
By signing th form,I hereby certiJj'that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: fj Yes or E3No with 15A NCAC 02C.0100 or 15A NCACdl2C.0200 Well Construction Standards and that a
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. a4
r,
�a t.� ---
repair under#21 remarks section or on the buck of this firrnt. 1�'��.... , �
23.Site diagram or additional well details: ,r 4�Y
R.For Ceoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additionab s�(Wails or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction•details. You may also attach additional pag ec s4'.2024
drilled: I SUBMITTAL INSTRUCTIONS
805 9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days oPlig piltiona of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following: 1
10.Static water level below top of casing:240 (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 n.
(i ) 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:
(Le.auger,rotary,cable,direct push,etc.)
Division ofWater Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1/2 Method of test: RIG 24c.For Water Supply&Injection Wells: In addition to sending the form to
PILLS the address(es) above, also submiti one copy of this form within 30 days of
13b.Disinfection type: Amount: s5 completion of well construction to the county health department of the county
where constructed. ,
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016