GW1-2022-10248_Well Construction - GW1_20221111

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This kwin can be used for single or multiple wells
1.Well Contractor information:
14.:WATER ZONES
GARRETT CLYDE BANKS FROM TO DESCRIPTION
Well Contractor Name ft. ft. j
4519-A ft. ft. k
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LiNER(if a"`Geable
FROM TO DIAMETER: THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 37 ft- 6 1/4 j m #21 1 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo '
22100111197 FROM TO DIAMETER THICKNESS r MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State.Variance,hnjection,etc.) ft. ft. i in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑A gricultural ❑Municipal/Public
❑Geothennal(Heating/Cooling Supply) 'lResidential Water SuPPIY(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply 18 GROUT
pp y(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 fL 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑AquiterRecharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.`DRILLING iLOG(attach additional-sheets if necessary)
❑Geothennal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 37 ft. OVER BURDEN
8-11-2022 37 ft 205 ft GRANITE
4.Date Well(s)Completed: Well iD#
ft. ft.
5a.Well Location:
CMH Inc.
9 �w
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
127 Two Wheel Drive Hendersonville, NC 28792 ft. rt. NOV 1-12022
Physical Address,City,and Zip 21.REMARKS-r . ✓
Henderson 9599776568 Dwroiaoo
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)
N N *b R.A 10-19-2022
Sig ial u—rerol`Cetliffeg Well Contractor ! Date
6.is(are)the well(s): ❑✓Permanent or []Temporary Br signing this form,1 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 ElNo copy q/this record has been provided to the well owner.
/l this is a repair,till out known well con.siruction inlbrrnalion and explain the nature ofthe
repair under#21 remarks section or on the back o/'this form. 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 to
additional pages if necessary.
For multiple injection or non-water svpplr wells ONLY with the saute construction,you can
suhmil one frmrn. 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 a ells list all depths r#different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:
30 Division of Water Resources,Information Processing Unit,
(ft.)
If irc.ter tevel is above casing use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection 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
(gp ) 24c.For Water Supply&Injection'Wells:
13a.Yield m 6 Method of test: RIG ,
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.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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