GW1--04509_Well Construction - GW1_20230713

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 DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. • ft.
NC Well Contractor Certification Number 15.'.°OUTERCA lfsf .(ftir;multi,caseSTq'elFs);OR+V1NEti(tC'ipptic`atit4j � M «"
FROM TO DIAMETER THICKNESS MATERIAL,
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft, 56 ft. 6 1/4 in• #21 Pvc
Company Name
16A INNER'CAS(lh'Gblet UBt)VG:(geptl(eitiial dosed-loojt)'WWAIAx
055-2023-0301 FROaI DIAMETER THICKNESS MMATERIAI,
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): t.17 SCREEN a 44§? IONAM AMMIMMIMVAMMS1=
Water Supply Well: FROM . TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) (]Residential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) r<1R:GROt1T': V V , °�� �Mli ' ` x * F r.rx
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Tnigation 0 ft' 20 ft• Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft. Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation .19/SANDIGRA;VEL.PAGK>(it.ip(ftiead7e) s iM *Ntf MV'—. A:`
❑Aquifer Storage and Recovery ❑Salinity Barrier FROMTO MATERIAL EMPLACEMENT METHOD
[t. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology 0 Subsidence Control
20: 1t1GIANG (104itinil addtkanilsheets.iLnecessarv)'.`' 4V ,4',
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 56 ft• OVER BURDEN
5-20-2023 56 ft• 205 ft• GRANITE
4.Date Well(s)Completed: Well ID# R. ft. _
5a.Well Location: ft. ft. F.c.y"r1.....
•" i .,., ;_,
Cody Henson ft. ft. : . L.
k?i�(:�r �aT l
Facility/Owner Name Facility ID#(if applicable) ft. ft. JULJU I 2 23
153 Oseetah Lane Hendersonville, NC 28792 ft. ft. Inficc i i/4 1 ' •++may (yt
Physical Address,City,and Zip .21,RRi MARKS r, .. n 9r'7WW?:MU 'Afi +r `e , IVY' ;
Henderson 0611194098 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 IaUlong is sufficient) C
r//✓�)
� �n �
N W 05/26/2023
Signature of Celt Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By 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 No copy of this record has been provided to the well owner.
If this is a rwair.fill out known well construction information and explain the nature oldie
repair under#21 remario section or on the back ofthis 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 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: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(4)200'and 2(000) construction to the following:
10.Static water level below top of casing: 30 (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 Injection 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.c.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
I
13a.Yield(gpm) 1 0 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount 25 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