GW1-2022-07714_Well Construction - GW1_20220819

WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.:Si'rCTERy tJ11E .4
GARRETT CLYDE BANKS FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft.
NC Well Contractor Certification Number W--";1or mitlti. OGPERf a ti¢b "
DIAFTFRRSS
FROM TO ICKNE i 1ATFRIA1,
CLYDE SAWYERS & SON WELL & PUMP INC +1 A. 43 ft- 6 vs i in- #21 PVC
Company Name 16i tN VERCtiS1G.t7R"T,U$1111C> tlierma[.clbs¢d too''.;; Y
22100103404 FROM DIAMKTKR THICKNESS MATERIAL
2.Well Construction Permit#: rt. rt. in.
List all applicable well permits(i.e.County,Statc,Variance,Injection,etc.)
3.Well Use(check well use): i.li;$GR_ EFAN-, `.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS , MATERIAL
❑Agricultural ❑MunicipaVPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. ft. rn.
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑llri ation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well: t't ft
❑Monitoring ❑Recovery
injection Well:
❑Aquifer Recharge ❑Groundwater Remediation19zANA1(;12a'`+1�1
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
'''20 D1277�T4 Zt1G'a iacH ntliliti nal hc¢ts:rfieceisaty a
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness soillrmk tv a gr.in size,etc.)
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 ft. 3 ft. OVER BURDEN
07-13-22022 43 ft- 305 ft. GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location:
ANDREW MOSS ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. G
430 LANNING RD HENDERSONVILLE -
rt. ft. Irtfiu,snis:lcn Pr' r,,+' Ur-
Physical Address,City,and Zip
HENDERSON 9681651221
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) 0A
Nn AA 07-20-2022
Signature of Certj'M Well Contractor Date
6.is(are)the well(s): RIPermanent or ❑Temporary
By signing this form,1 berehy certify that the wells/was(were)constructed in a(cordance
with 15A NCAC 02C.0/00 nr I sA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or F)No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction it furnratiun and explain the nature of the
repair render#21 remarkv section or on the hack t f this lame. 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 ifnecessary.
For multiple iqjection or nor-water supply wells ONLY with the.came construction,you can
submit one fo m. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 305 (ft.) 24a. For All Wells: Submit this forth within 30 days of completion of well
For multiple wells list all depthv it diffl rent(example-3(a�200'and 2(tylOO') construction to the following:
10.Static water level below top of casing:40 (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 Infection Wells ONLY: In addition to sending the form to the address in
ROTARY 24aabove, 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.) 4
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) 3 Method of test RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: Amount: 20 well construction to the county health department of the county where
constructed.
Form G W-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013