GW1-2022-03942_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS FR•WATER Zt)NES
RO�I TO DESCRIPTION
Well Connector Name ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a`Gcable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 179 It- 16.25 #21 1 PVC
Company Name
16.INNER CASING OR TUBING eothermal closed-lob
19100113162 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State. Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIA I,
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ]Residential Water SuPP1Y(single) ft. ft. in•;
❑1ndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. Tt.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation l9.SAND/GRAY,EL'PACK if appiicable
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Expenmcntal Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets`if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness,soil/rock tylic,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 79 e. OVER BURDEN
3-8-2022 205 rt• 205 rt• GRANITE
4.Date Well(s)Completed: Well TD#
ft. rt.
5a.Well Location:
CMH Homes Inc
Facility/Owner Name Facility 1D#(if applicable) ft. ft.
174 Moss Hill Drive Hendersonville, nc 28792 ft. ft. APR 12 J q
Physical Address,City,and Zip 21.REMARKS
Henderson 9681103434 �,r.k-,' %xx
County Parcel Identification No.(PIN) Uiq$'
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
3-11-2022
N W
Signature ofCerti Well Contractor Date
6.Is(are)the well(s): @Permanent or ❑Temporary By signing this form,1 hereby certgJ that the well(s)was(were)constructed in accordance
With 15A NCAC 02C.0100 or 15A 1VCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or FlNo copy of this record has been provided to'the net/owner.
//this is a repair,,Jill out known well construction information and explain the nature gfthe
repair under 42/remarks section or on the hack of'this jornn. 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: 1 construction details. You may also attach additional pages if necessary.
For nudtiple injection or non-water.suppli wells ONLY with the same construction,you can
�bmit one/arm SUBMITTAL INSTUCTIONS
9.'Total well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i/'diftrent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 30 (ft,) Division of Water Resources,Information Processing Unit,
inter level is above casing,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:
0.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)4 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type. PILLS Amount: 20 well construction to the county health department of the county where
constructed.
Fume GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013