GW1-2022-02902_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
GARRETT CLYDE BANKS F4.WATER 'rO
FROM "1'O DESCRIPTION
Well Contractor Name
ft. ft.
4519-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER(if a livable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 132 ft 6 1/8 #21 1 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
21100117878 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable nrll permits(i.e.Cowart State. Variance,Gjection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSI%E THICKNESS MATERIAL
ft. fL❑Aricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) IResidential Water SuPPIY(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 f. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑NI on i tori ng ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonmwater Drainage
ft. ft.
❑Experimental"rechnology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 32 ft. OVER BURDEN
12-20-2021 32 ft- 805 ft- GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Worley Group Inc ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Judson Ridge Road Hendersonville, NC 28792 ft. ft.
Physical Address,City.and Zip 21.REMARKS —
Henderson 9622690461
Cotmty Parcel Identification No.(PIN)
`,b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: f' l77
22-Certification:
(ifwell field.one lat/long is sufficient)
N W 2-8-2022
Signature ofCeruM Well Contractor Dale
6.Is(are)the well(s): RPermanent or ❑Temporary B-v signing this lbrnn, l hereby certi(i,that the+vell(s)was(were)constructed in accordance
with 15A NCAC 02C.0/00 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofthis record has been provided to the well owner.
//'this is it repair,fill out known well construction inlornmlion and eevplain the nature of the
repair under#21 remarks section or on the back o/'this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also'attach additional pages if necessary.
For mndtilde injerliun ur nun-+rater supply wells ONLY with the same construction,iou can
'ahniii one/orin, SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 805 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i/'d4jerem(exannple-3@,200'and 2 cd100') construction to the following:
10.Static water level below top of casing: 240 (ft,) Division of Water Resources,Information Processing Unit,
If wale/etc/is above easing.use'+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
ROTARY 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.aueer.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 m 1 Method of test: RIG 24c.For Water Supply&Injection Wells:
(gp ) Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: PILLS Amount: 35 well construction to the county heialth department of the countywhere
constructed.
Form:.GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013