GW1-2022-03944_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 14 F;wATERzoxEsR Oi•'I TO DESCRIPTION
Well Connector Name
ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased weUS)OR LINER if a "Geable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 90 ft' 16.25 #21 1 PVC
Company Name 16.INNER CASING OR TUBING eothermalclosed-loo
19100113111 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 MATF.RIA 1,
ft. ft.❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water SuPP1Y(single) ft. f. in.
01ndustrial/Commercial ❑ F
Residential Water Supply(shared) 18.
GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft' 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation t9.,SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwatcr Drainage
rt. rr.
❑Experimental Technology ❑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.
❑Geothenmal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 90 rt. OVER BURDEN
3-8_2022 90 ft• 185 ft• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft. �, @ M, 6,
CMH Homes Inc.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
194 Moss Hill Drive Hendersonville, NC 28792
Phvsical Address,City.and Zip 21 REMARKS ` 1 i• row`11011` tar n
Henderson 9681104453 '
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one tat/long is sufficient)
N Nt Sig 3-11-2022
nature ofCenn Well Contractor Date
6,Is(are)the well(s): ❑O Permanent or ❑Temporary Br signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo cop),of this record has been provided to the well owner.
/(this is it repair,fill out known well consiruclion information and etrplain the nature ofthe
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: 1 construction details. You may also lattach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit One)nrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 185 (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@/00') construction to the following:
10.Static water level below top of casing: 30 Division of Water Resources,Information Processing Unit,
(ft.)
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection 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.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) 5 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.
i
Form G W-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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