GW1-2022-06135_Well Construction - GW1_20220628

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
GARRETT CLYDE BANKS 14'WATER`zbNEs F
FROM TO DESCRIPTT
ION
Well Contractor Name ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number 15:OUTER CASING(for uulti-cased yvells)OR LINER'(ifa .Hcable),'
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft' 145 ft- 6 1/8 i" #21 PVC
Company Name MANNER CASING'OR TUBING "eothermal closed-loci
22100105374 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) rt. ft.
in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single)
❑Industrial/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:
rt. rt.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a 'licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
f:. ft.
❑Experimental Technology ❑Subsidenc-.Control
20.DRILLING LOG(attach additional sheets if necessary)
[]Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soilfrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 5 ft. OVER BURDEN
45 ft- 205 ft. GRANITE
4.Date Well(s)Completed: 205 Well ID#
ft. ft.
5a.Well Location:
CMH Homes Inc ft. rt.
Facility/Owner Name Facility lD#(if applicable) ft ft ' kn p
75 Two Wheel Drive Lot 4 Hendersonville, NC 28792 rt. rt. JUN `I
Physical Address,City,and Zip 21 REMARKS
Henderson 4599881373 lniGT ,,;:q g ma0z zing Unit
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
N w 6-13-2022
s!;;atMfCc11ttTK Well Contractor Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this forth,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 ONo coP),of this record has been provided to the well owner.
If1hi.s is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back ojthisfornt. 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 multiple irnjcetion or non-water supply wells ONLY with the same construction,yont can
SUBMITTAL INSTUCTIONS
.subunit onefa•rn.
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 ifdglJ rent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
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) 30 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.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013