GW1-2022-09442_Well Construction - GW1_20221017

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor information:
GARRETT CLYDE BANKS FR WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
4519-A
NC Well Contractor Certification Number 15.OUTER CASING far multi-cased"wells)OR LINER(if a tih able)
FROM TO DIAMETERS THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 31 ft 6 1/8 #21 1 PVC
Company Name 46.INNERCASING OR TUBING(geothermal closed-loo
22120104140 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. rt. in.
List all applicable well permits(i.e.County,State.Variance,h jection,etc.) ft 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
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑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 ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Agltiter Storage and Recovery ❑ FROM TO MATERIAL EMPLACEMENT METHOD
Salinity Barrier ft. ft.
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach addi[ional'sheets if necessary)'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 110 ft. OVER BURDEN
7-15-2022 110 tt• 505 rt• GRANITE
4.Date Well(s)Completed: Well rD#
fc. rt.
5a.Well Location:
Chelsea Nix
fc. ft.
Facility/Owner Name Facility iD#(ifapplicable) n ,"a
127 Peaceful View Trail Hendersonville, NC 28792
ft. ft.
Physical Address,City,and Zip 21:REMARKS OCT L
Henderson 0602030705
County Parcel Identification No.(PIN) l av --OG
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
N w -0-6 9-6-2022
Signature of Certr Well Contractor Dale
6.is(are)the well(s): ❑�Permanent or ❑Temporary BY signing this form,I hereby certify drat the well(s)was(were)constructed in accordance
with 15,4 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 copy of this record has been provided to the well owner.
ffthis is a repair,•/ill out known well construction hijbrmation and erplain the nature ofthe
repair ander#21 remarks section or an the back of this fornt. 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: I construction details. You may also attach additional pages ifnecessary.
For mdtiple injection or non-water supply wells ONLY with the same construction,you can
suhmit one_ nn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 505 (ft.) 24a. For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths tfdrj/erent(example-3 tt 200'mud 2G100') construction to the following:
60 Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: (ft.)
I/lrater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter 6.25 (in.) 24b.For Iniection Wells ONLY: iIn 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) 1 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
131m.Disinfection type:
PILLS Amount: 35 well construction to the county health department of the county where
constructed. j
Form 6W-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013