GW1--05622_Well Construction - GW1_20240916

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Kolby Mitchel Sawyers •
liliiNVAttltAi EW, _: : °r T n;, 'l �y ,
FROST TO DESCRIPTION
Well Contractor Name
ft. ft.
4471-A
ft. ft.
NC Well Contractor Certification Number 15,Ot3hER OX.S1NG(for`,f iutH ca5eifi elk)Olit1NEie(il ap eahteM.1
CLYDE SAWYERS & SON WELL & PUMP INC FROM TO DIAMETER THICKNESS MATERIAL
Company Name +1 ft• 38 ,i,6 ft. 6 25 P tin #21 PVC
22120100628 Ie-iNNtiveNs16 UR 7'CtRlt�a ailf mat•closcd-foop) � M�''.•-,M ,x`04,i''''
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 Sappy'Well:
.IM 'ORY,EVI""s"t�" - `t.tI`'dam t : .I. 9..a : .k'la: fi
FROMTO DIAME7 Eli ST OT SIZE THICKNESS MATERIAL
Agricultural Municipal/Publicft, ft. in.
Geothermal(Hcating/C_ooling Supply) Et Residential Water Supply(single) ft. ft. in.
industrial/Commercial ['Residential Water Supply(shared) w t8,1G12OUT ":SR NW'c ` ,Z'".ftf:,V" , '` ° .1,wr
Irigation FROM TO MATERIAL RM PLACEMENT METHOD SAMOUNT
Non-Wafer Supply Well: 0 ft 20 ft- Bentonite Pumped
Monitoring 0Recovery ft. ft. j . - Cap Top with Bentomite chips
Injection Well:-
ft- ft.
Aquifer Recharge 0Groundwater Remediation
19.SM1Sll/GRYSV'RY,'PACl (f•npPliuit lal,to s r e 4M;ems. r;'N FZz i...>
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL' EMPLACEMENT METHOD
' Aquifer Test 0Stonnwater Drainage ft. ft. it
pExperimental Technology 0 Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer '..2tl'DRittINGIOCti llariaddito al`'sheefsif`iiecessan} `FAVJ> � ,t ;
Fri TO DESCRIPTION(color-hardness,soil/rock Ow.gram size,etc.)
°Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 , 38 ft. OVER BURDEN
t i
4.Dale Well(s)Completed:8-1-2024 Well ID# •
38 ft 125 ft• GRANITE
ft. ft. '
5a.Well Location: •
ETHAN SCHWARTZ ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft, ft.
r 55 HARMONY FOREST TRAIL HENDERSONVILLE, NC ft. ft.
I Physical Address,City,and Zip ft. ft.
HENDERSON 9536561314ig11411ENIMIX.SW4',A040410714:MM:agrANIAVEMUWAFM,atet
County Parcel IdentificatioirNo.(PiN) •
•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/lon is sufficient)b 22.Certification:
•
N r 8-2-2024
6.is arc the wells X. Permanent or ['Temporary Sigma.e offer ed�wtcllflunhaclor Date
Is(are) O� � P ry
By signing th'/orm,I hereby cerTifi'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ID yes or,DNo with 15A:VCAC 02C.0100 or I SA NC;IC,(.f/>C'.1120!)Well Co t. M7F7ih Sfandards•apd uwa.
If this is a repair.Ill out known well construction information and explain,/,e•nature bfdie cops of this record has been provided to the well owner. t,L'.A,•- z `�
•
rspair under#21 remarks section or on the hack tfthis form. 23.Site diagram or additional well details• CC tt n n q
R.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same ' You may use the back of this page to provide additional SEP'eidc Hil2t�•2t4e11
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
e,
drilled: ' bete ,l r,n ?F1r ;:y Lif,2€
SUBMITTAL INSTRUCTIONS . Di.S-;;310G
9.Total well depth below land surface: 125 • - i (ft.).\ 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd Brent(example-3 q,200'ani12 g.•100'1 \construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,information Processing Unit,
Iiwater 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
It i
13a.Yield(gpm) 30 Method of test: RIG 24c. For Water Supply&Iniect on Wells: In addition to sending the form to
PILLS the address(es) above, also suljmit one copy of this form within 30 days of
13b.Disinfection type: Amount: 20 completion of;well constructiois, to the county health department of the county
where constructed.
Form(iW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-20I6