GW1-2022-05276_Well Construction - GW1_20220526

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor information:
GARRETT CLYDE BANKS 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
4519—A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased erells)OR LINER(if a licable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 6g ft• 6 1/8 in. #21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
21100121857 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Cwau),,State.Variance,hrjection,etc.)
f[. R. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) EIResidential Water SuPP1Y(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
El Irrigation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FRONI TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) 0 fc. 69 ft. OVER BURDEN
4.Date Well(s)Completed: 4-25-2022 Well ID# 69 ft' 285 ft. GRANITE
fc. rt.
Na.Well Location: rt. tt. tom + - `?i _r:• '
CMH Inc
ft. ft. 7
Facility/Owner Name Facility iD#(if applicable) ft. ft. a
73 Four Wheel Drive Hendersonville, NC 28792
Phv.,ical Address,City,and Zip 21.REMARKS
Henderson 9599880630
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
01'well field,one lat/long is sufficient)
N 04-28-2022
Signature ofCeru Well Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this form:,1 hereby certijv that the well(s)was(were)constructed in accordance
with ISA 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 cop),gf1his record has been provided to the well owner.
l/this is a repair,fill out known well construction h formation and explain the nature ofthe
repair under#21 remarks section or on the back o('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: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water•supply wells ONLY with the saute construction,you can
submit one Jrn•m. O 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 ivel/s list all depths ffelf Jerent(example-3 ct 200'and 2@/00') construction to the following:
10.Static water level below top of casing: 60 Division of Water Resources,Information Processing Unit,
I/'water level is above casing,use..+•' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection 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) 3 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: 30 well construction to the county health department of the county where
constructed.
Forage GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013