GW1-2022-05278_Well Construction - GW1_20220526

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS FR WATER ZONES PT
FROM TO DESCRIPTION
Well Contractor Name
4519-A
NC Well Contractor Certification Number 5.OUTERCASING for multi-casediwells),OR LINER(if:a'.licable)`
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. 71 ft. 6 1/8 i" #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)'
21100121858 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable Nell permits(i.e.Counq,,State. Variance,hyection,etc.) ft. rL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) t7Residential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑ FR
Residential Water Supply(shared) GROUT I -?
OhL TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. rt.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
El Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology []Subsidence Control
20-DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) 0 ft. 20 rt. OVER BURDEN
4-21-2022 20 f- 325 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. rt.
Sa.Well Location:
CMH Inc ft. rt. 4_�
Facility/Owner Name Facility ID#(ifapplicable) 2OL-
ft. ft. 7
Four Wheel Dricve Lot 5 Hendersonville, NC 28792 fc. rt.
Physical Address,City,and Zip 21.REMARKS1-
Henderson 9599882708
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) __0
N W 05/02/2022
Sig nature of certt Well Contractor Dale
6.Is(are)the well(s): OPermanent or []Temporary BY signing this form,I hereby certify that the well(s)was(were)constructed in accordance
ivith 15A NCAC 02C.0/00 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or ONo cop),gfthis record has been provided to the well owner.
Ifthi.v is a repair,Jill out known well construction information and explain the nature of the
repair under#2l 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: 1 construction details. You may also attach additional pages if necessary.
For muhiple injection or non-water supply wells ONLY with the same construction,you can
submit onefarm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 325 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ff'QJ&ent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 50 (ft) Division of Water Resources,Information Processing Unit,
If muter level is ahove 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.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: 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.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013