GW1-2022-05279_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:
14.
GARRETT CLYDE BANKS ONES
FROM ER 'to t0 DESCRIPTION
Well Contractor Name
ft. ft. '
4519-A
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a Gcable)
FROM TU DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 56 ft• 6 1/8 #21 1 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
21100117759 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State. Variance,hyection,etc.)
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
ft. ft. In
❑Geothermal(Heating/Cooling Supply) OResidenial Water SuPP1Y(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft' 56 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FRO31 TO MATERIAL EMPLACEMENT METHOD
❑Agttiiel•Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stonmwatcr Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessar
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21Remarks) 0 ft. 56 ft. OVERBURDEN
05/05/2022 56 ft, 245 ft. GRANITE
4.Date Well(s)Completed: Well ID# rn
5a.Well Location:
Paul Whitt ft. ft. MAY —
Faeifity/Owner Name Facility ID#(ifapplicable)
ft. ft.
70 JP Huggins Drive Hendersonville, NC 28792
Phvsical Address,Cit an Zi ^-• C`4{ji uv
y a P 21.REMARKS a'�' v"'
Henderson
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one]at/long is sufficient)
_T a
N N 5/17/2022
Signature ofCertift4 Well Contractor Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary BP signing this firm.1 herebv cerdfv that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Mell Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or E lNo cope gfthis record has been provided to the well owner.
if this is a repair,fill out known well construction in%nrmation and explain the nature ofthe
repair under#21 rentarks section at-on the back ofthis/ortn. 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 svupph•wells ONLY with the same construction,you can
sahunit one%arn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 245 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi(jerent(example-3 ct)200'and 2G100') construction to the following:
10.Static water level below top of casing: 50 (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 Center,Raleigh,NC 27699-1636
13tt.Yield(gpm) Method of test:
7 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.
Fora GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013