GW1--03551_Well Construction - GW1_20230519

WELL CONSTRUCTION RECORD For Interne Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT COLLIN BANKS F
w4.��``trEefiz°
ROI\I TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft.
1�Lll1 GER t ASt#YIt3 eased heltiLINER=: iicabtc'
NC Well Contractor Certification Number FROM TO ,fortnii DIAMRTFR ls O THICKNESS' I MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 1115 ft- 16 1/4 i" #21 1 PVC
Company Name
1 1Y1yt RtCiS$t1YCr t7R,T;l1BlNGwegthermat clo"sed400, V;`JWM� �
055-2022-0521 FROM 1'O DIAMN'rER 'THICKNESS MA TRIM
2.Well Construction Permit#: ft ft. '"•
List all applicable Hell permits(i.e.County,State,Variance,Injec(ion,etc.)
ft. ft. in.
3.Well Use(check well use): �J748GREENa F ME.:
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft.❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/CoolingSupply) EIResidential Water Supply(sin(single) in,
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL F.MPLACEMF.NT METHOD&AMOUNT
❑ir; ation 0 et. 20 fi- Bentonite Pumped
Non-Water Supply Well:
ft. rt. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: t't. ft.
[]Aquifer Recharge ❑Groundwater Remediation lAi-SANE/O1ZiiV.ELI'ACKf h ''`Haft le; ".` " X""
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
.21t.%IfR1LrT�1N �()G.{aftactrnJdihanuf"sheefs`'if;'ne�`ce3sui•`-';, '�
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soitfrock type.gnin size,etc.)
❑Geothermal Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 ft• 115 ft• OVER BURDEN
4-28-2023 115 fr• 805 ft• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft.
Franklin Gilliland
ft. ft.
Facility/Owner Name Facility ID#(ifapplicable)
403 George Chastain Road Hendersonville, NC 28792 L 49. Li J
Physical Address,City,and Zip u2f Rj V1ARK$,z a p,ri. ' ;�? 5
Henderson 9620330792 This 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 latllong is sufficient)
t�A
N `,l, n AA 5-3-2023
Signature of Certt Well Contractor Dale
6.is(are)the well(s): OPermanent or ❑Temporary By sibnting this form,1 herehv certify that the well(s)ryas(were)constructed in accordance
with 15A NCAC 02C.0100 nr 15A NCAC 03C.0200 Nell Construction Standardv and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain lire nature of the
repair under#21 remar1w section or on the back e fthis 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: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form, SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 805 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ij'different(example-3 tin 00'and 2(a.100) construction to the following:
10.Static water level below top of casing: 300 (ft) Division of Water Resources,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 Ceniter,Raleigh,NC 27699-1636
13a.Yield(gpm) 1/4 Method of test: RIG
24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this formlwithin 30 days ofcompletion of
13b.Disinfection type: Amount: 35 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013