GW1-2023-02856_Well Construction - GW1_20230418

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT COLLIN BANKS �FROM TO �. DE CRr TT
DN
Well Contractor Name ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number
15<UtlCt. famaiti ca i' `tli�fE its" t °"
FROM TO DIAMETER THICKNESS AtATF.RIAi.
CLYDE SAWYERS & SON WELL & PUMP INC +1 It. 30 ft. 6 1/4 in. #21 PVC
Company Name "�l ,.ammo fNGO.AIUA139G cotti raiat`clrs d=to" r,. ``n
055-2022-0043 FROM 1'0 DIAMETER 'THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,ete.1 ft. ft. in.
3.Well Use(check well use): i7S1h g; ,
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public tt. tt. in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) FROM TO«• MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20 ft' Bentonite Pumped
Non-Water Supply Well:
rt. tt. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation f9i9e1;?W1GPAVET..;kArX' .a 'eebte
LA
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO
tt. ft. IYLITERIAL EDIP CEMENT 51ETHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
"9�T1_111�1��1:t� f�tFd� �udtlrtidn:iK"�fteet'�i>necessa ��:i.. �;a
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiVrmk type.gmin size,etc.)
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 tt 30 ft OVER BURDEN
3-22-2023 30 ft 505 ft GR_ANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location:
ft. ft.
Paul and Irene Flay ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. - -•-: ra. „.^
1604 Mtn Grove Lane Hendersonville, ft. ft.NC 28792 ` " ; '` ►ln*5
v'�'a�.��L;.•
Physical Address,City,and Zip ER ARK$ ' ••" -:0 §_ s ,s XJMRI
Henderson 9661972249 Well WAS SELF CERTIFIED
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.CertiYication:
(if well field,one lat/iong is sufficient)
N `� 3-24-2023
Signature of Cerh Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby cer4fy that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair tinder#21 remarks-section or on the back of 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
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the came construction,you can
submit one form. 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 depth tJ'Jifjerent(example-3 dr 00'and 2(a100� construction to the following:
10.Static water level below top of casing: 120 (ft,) Division of Water Reso rces,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 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
13a.Yield(gpm) 7 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: 35 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