GW1--06085_Well Construction - GW1_20230921

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WELL CONSTRUCTION RECORD • For Internal Use ONLY:
This form can be used for single or multiple wells '
1.Well Contractor Information: I
GARRETT COLLIN BANKS 44:MATEi ONI8S ., 41.., .., .._ 73. .i$ T x _
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft. 1
NC Well Contractor Certification Number 45.-O ER'C�NG(for`.mu7tI casetLwi�lls)OR J lNER fifappiicable) d^..-
FROM TO DIAMETERI THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 173 ft• 6 1/4 t in' #21 Pvc
Company Name :"'I0.lIVNER;CASING OR'.Tf7ttINC'(gatitliChi allelosed loop}..;i
OSS-2023-1083 FROM TO DIAMETER; THICKNESS MATERIAL
2.Well Construction Permit th ft, ft. tn.
List all applicable well permits i.e.County,State,Variance,Injection,etc.) ft. ft.
3.Well Use(check well use):
°l7:SCREEN:',..,:'‘'l& .,. I ff4.1-k. _ � ��
.. �...
Water Supply Well: FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAI.
ID Agricultural ❑Municipal/Public ft. ft. in.,
ft. ft.❑Geothermal(Heating/Cooling Supply) PResidential Water Supply(single) in.,
❑Industrial/Commercial ❑Residential Water Supply(shared) ;i8:'GROIIT�, ' '� - - - '--''- '- '" ...- ""
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. ft
Non-Water Supply Well: 20 Bentonite Pumped
ft. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection'Well: ft. ft.
❑Aquifer Recharge • ❑Groundwater Remediation IANDdGRAYFla'ARK(if appiieoh}4} . ;• g <,,,
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑ExperimcntalTechnology ❑Subsidence Control li20110R DIND.ILOB(atitiafaddittbia sfi€etsifnetessar
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiUrock type,gram size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2]Remarks) 0 ft• 173 ft• 1 OVER BURDEN
09/11/2023 173 ft• 285 ft• GRANITE
4.Date Well(s)Completed: Well ID#_
ft. ft. r.y 5a.Well Location: ft. G '��,
Lift. ft. 6L L'L..[.
Cody Henson ft. ft. •
•
SEP 12023
Facility/Owner Name Facility ID#(if applicable)- ft. ft.
253 Woodrow Way, Hendersonville, 28792 ft. ft. jiliacxr sn cof;r 'ig Url
Physical Address,City,and Zip • $31�RRARIF�r,' _ .ter.�- t}�_� •,•.zra �,,, ,. ,q'�-`t' �.°��` ,, ..
Henderson 10010835 TINS Welk LAY' SA (_ZYst; tc
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 C �
09/12/2023
Signature ofCertt WellContractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary i•
By signing this form,I hereby mills that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo 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 I
repair under#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
8.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 sante construction,you can ,
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 285 (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@200'and 2@100') construction to the following:
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10.Static water level below top of casing: 20 (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: ln,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.) j
Division of Water Resources,iUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service CI nter,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS 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 R sources Revised August 2013