GW1-2023-02859_Well Construction - GW1_20230418

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
GARRETT COLLIN BANKS � � r .
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number
a1 'fot�> ;ita E t cast:t flan
FROM TO DIAMETER THICKNFSS A[ATF.RiAi.
CLYDE SAWYERS & SON WELL & PUMP INC +1 1- 72 ft. 6 1/4 in. #21 PVC
Company Name QgN1 ll fi C-AS114 OR 1 I1B719G `eoi) itiis}l clitiseil=toy z ": ,t._ .
19100112495 FROM DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in•
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in•
3.Well Use check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public it. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACF.MF.NT METHOD&AMOUNT
❑hTi ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery et' ft• Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑Aqui fey Recharge ❑GroundwaterRemediation
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery El Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology El Subsidence Control
�Tx attacti�atl"diti�ii: shcets ii'Si�ces'sa�` i}
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiyrmk type.grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 72 ft. OVER BURDEN
3-30-23 72 fc 205 ff GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location:
CMH HOMES INC ft. fr. L'11 1 8 2023
Facility/Owner Name Facility ID#(if applicable)
221 MOSS HILL DRIVE HENDERSONVILLE, NC 28792 "
ft. ft
Physical Address,City,and Zip
HENDERSON 9681106711 WELL WAS SELF CERTIFIED
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 W 3-31-2023
Signature of Cent Well Contractor Date
6.is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,I her•ehv certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I SA NCAC 02C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No copy of this 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 tender#21 remarks,section or on the back oj'this farm. 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.
For multiple injection or non-water supply wells ONLY with the saute construction,you can
submit one form. 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 wells list all depths if'dii ferent(example-3 dr 00'and 2(ay100) construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If stater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.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) Method of test:
7 RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this fortn within 30 days of completion of
13b.Disinfection type: Amount• 20 well construction to the county health department of the county where
constructed. I
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water R sources Revised August 2013
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