GW1-2022-10247_Well Construction - GW1_20221111

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This Ihrm can be used Ibr single or multiple wells
I.Well Contractor Information:
GARRETT CLYDE BANKS FR•WATER ZONES i
FROM I DESCRIPTION
\Nell Contractor Name
ft. ft.
4519-A ft. ft. f
NC'.Nall Contractor Certification Number 15.OUTER CASING for multi-casedl'welIs)OR LINER if a Gcable
FROM TO DIAMETER I THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 fc. 59 ft• 6 1/4 ! 'n #21 1 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
055-2022-0147 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
Li i all applicable well permits(i.e.County,State, Variance,Injection,etc.) ft. fL in.
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3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER� SLOT SIZE. THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public
❑Geothermal Heating Cooling Supply) EIResidential Water Supply ft. ft. in.
( � d PP Y) PP Y
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrrigation 0 fl. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Nlon itoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquilcr Test ❑Stormwater Drainage
ft. ft.
❑Fsperinicntal Technology []Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothennal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothennal(Heating/Cooling Retum) ❑Other(ex lain under#21 Remarks) 0 ft. 59 ft. OVER BURDEN
9-27-2022 59 fc, 205 ft- GRANITE
�.Date Well(s)Completed: Well 1D#
ft. ft.
5a.Well Location: ft. ft. IF I
Douglas Jones
Facility/Omer Name Facility ID#(ifapplicablc)
46 Fruitland Road Hendersonville, NC 28792 NI1
rt. rc.
Physical Address,City,and Zip 21.REMARKS `i1ft+
Henderson 9680049217 j
Count. Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one fat/long is sufficient)
46 N N 10-19-2022
Signature ofCent Well Contractor Date
6.Is(are)the well(s): ❑�Permanent or ❑Temporary By signing this Jonn,1 hereby certily that the wells)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 END cony gf1his record has been provided ur the well owner.
//1hi.s i.s a repair.Jill oul known well construction infi ntalion and«rplain the nature of the
repair under#2/remarks section or on the back ofdris 1brm. 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.
Fnr multiple inieclion or notr-water.supply wells ONLY with the same construction,you can _
cuhruit mte,(artn. SUBMITTAL INSTUCTIONS
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 welly list all depths rfdi(jcrenl(example-3 i7t 200'and 2@100') construction to the following:
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10.Static water level below top of casing 20 (ft,) Division of Water Resources,Information Processing Unit,
I/walcr/ere/it above casing,use"+- 1617 Mail Service Center,Raleigh,NC 27699-1617
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I I.dorchole diameter 6.25 (in.) 24b.For Infection 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.aiwer.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
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13a.Yield(gpm) 100 Method of test: RIG 24c.For Water Supply&Injection`Wells:
Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: PILLS Amount: 30 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 Re ources Revised August 2013
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