GW1--06657_Well Construction - GW1_20241112

li Wrt Form. `j
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1
1.Well Contractor Information: i
Kolby Mitchel Sawyers "z4:.��-WITI MflNES* - _ . O x
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A
ft. ft.
NC Well Contractor Certification Number F15 Ot1TER GASII fG{for tt t9 ca ed':Wells)bRlIINER(If up bcablei na
CLYDE SAWYERS &SON WELL & PUMP INC FROM TO MAMEI'tR 'THICKNESS mAnauAI.
+1 ft. 36 ft 6.25 j in- #21 PVC
Company Namc
OSS-2024-0062 lG.�lNlYtiM SIIV OIiTI[t3ti�G`{gco#fieroiuictascd-toop) -sue 4g-M;
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. i in.
3.Well Use(check well use): ft. ft. in.
W ater Supply Well: fit?:SGRE1 N .. ��. s '
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
AgriculturalMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)industrial/Commercial
ft. ft. in.
DResidenti Water Supply(shared) IBOROUT� & ���.. ;' ' _ ,', '
irrigation
DNon-Water Supply Well:
FROM TO MATERIAL ESi P1.ACFMF;NT METHOD&Asiourc1'
0 ft. 20 ft. Bentonite' Pumped
Monitoring
Injection Well:
Aquifer Recharge
Recovery ft. ft. Cap Top with Bentomite chips
ft. ft.
0 Groundwater Remediation yam,
19 SAND/ati Y:E15:1�r1 11.."�(if f-16 teittll`N) 3 + ''�..van: E ;igkN
Aquifer Storage and Recovery Salinity Barrier IRON TO MATERIAL EMPIr\CEMENT METHOD
Aquifer Test DStonnwater Drainage ft. ft.
ril Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) EITracer Z(t)Rltll lNGrl3ftGr(nttach addrtionaksheets lyre'essay})' '" -- i^
FROM TO DESCRIPTION(color.hardness.soil/rock type.gram size.etc.)
OGeothermal(Heating/Cooling Return) riOther(explain under#21 Remarks) 0 ft. 36 ft. OVER BURDEN
4.Date Well(s)Completed:9-13-2024 Weil 1D# 36 ft• 425 ft GRANITE - __
ft. ft. r 1" ' lSi.... . '.•-• 1
5a.Well Location: 1 ,r . �, .r,LI
KACEE GARREN ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
NOV 1 2 2024
648 DREAM VIEW DRIVE HENDERSONVILLE, NC 28792 ft. ft. 1 :�.�.•.,�.:: ,r• ; I.
Physical Address,City,and Zip ft. ft. (,t':'d s. 's tJ J
HENDERSON 10004033 i,.' l:; >R iv1,1;1tim,':.' „AMMO O . U : c ,`,, �� .
County Parcel Identification No.(PIN) WFI I WAS SFLE CFRTIFIFD
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lot/long is sufficient) 22.Certification:
N VI' 9-16-2024
6.Is(are)the well(s)1IIX Permanent or Temporary Sigma a of er edlh onlractor Date
By signing th form,I hereby certify that the well(s)was(were)constructed in accordance
7.is this a repair to an existing well: E3 Yes or 0No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair.,fill out known well construction information and explain tire nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this firrni.
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 well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS ,
9.Total well depth below land surface: 425 (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(7 I00') construction to the following:
10.Static water level below top of casing: 80 (ft.) Division of Water Resources,information Processing Unit,
I/'water level is above casing,use"+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 n.
(i ) 24b. For Infection 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 2 769 9-1 63 6
13a.Yield(gpm) 4 Method of test: RIG 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit oite copy of this form within 30 days of
13h.Disinfection type: PILLS Amount: 35 completion of well construction to th� county health department of the county
where constructed.
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Form('rW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016
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