GW1-2022-05280_Well Construction - GW1_20220526

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 .110
ROM1I 1'O DESCRIPTION
Well Contractor Name
rt. rt.
4519-A
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells)OR LINER(if a licable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 78 ft. 6 1/8 #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 21 1 001 21 860 ft. ft. in.
List all applicable well perruits(i.e.County,State.Variance,h fection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM ro DIAMETER SLOT SIZE THICKNESS MATERlnl.
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Cooling Supply) EIResidential Water Supply rt. ft. in.
( � � PP Y) PP Y
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FRO31 TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft' 20 ft, Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑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 ❑Stonnwatcr Drainage
ft. ft.
❑Experinmental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessar )
❑Geother nial(Closed Loop) ❑TIacel FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 it. 78 rt. OVER BURDEN
4-21-2022 78 rt 125 ft GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
CM H Inc ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
.51 Four Wheel Drive Hendersonville, NC 28792 MqY --
rt. rt.
Physical Address,City,and Zip 21.REMARKS
Henderson 9599880688 , ;;'.:;tVE
County Parcel Identification No.(PIN) �c�Yi
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one]at/long is sufficient)
' N N, 04-28-2022
Signature of Ceru Well Contractor Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary Br signing this form,I herebv certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or FlNo cop),of this record has been provided to the well owner.
If1his is a re pair.fill nut known well construction it fbrntation and explain the nature of the
repair under#21 rentarks section or on the back o/'this fornn. 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 ifnecessary.
Ru nuthiple injection ot•non-water.supph•wells ONLY with lire save construction,you can
sttbotil one fnrnt. SUBMITTAL INSTUCTiONS
9.Total well depth below land surface: 125 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For tnuluple wells list all depths f'dgjJ rent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 20 Division of Water Resources,Information Processing Unit,
Ihrater 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
13:1.Yield(gpm) Method of test:
30 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 countywhere
constructed.
Foram GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013