GW1-2022-07713_Well Construction - GW1_20220819

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS 14.
FROM FROM
ZONES
FROM 'f0 DESCRIPTION
Well Contractor Name
ft. tit.
4519-A f. fL I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased$;wells)OR-LINER(if a_. Gcable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft' 175 ft. 6 1/8 ' #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
22100104364 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. 1 in.
Litt all applicable well permits(i.e.Countl•..State, Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
f[. ft. in.
❑Agricultural ❑Municipal/Public
in:
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single)
01ndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft' 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑AquiferRecharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquiter Storage and Recovery ❑Salinity Barrier
❑Aquiter Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING'LOG-(attach additional sheets if necessary)
❑Gcothennal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/mck e, rain size,etc.
❑Gcothennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 75 ft. OVER BURDEN
7-14-2022 75 f`' 225 ft GRANITE
�.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well:Location:
Stanley Livingston
Facility/Owner Name Facility ID#(ifapplicable) r
tit. ft.
John Delk Road Minor sub lot 1 Hendersonville, NC 28792 ft. ft. AUG !
Phvsical Address,City,and Zip 21.REMARKS
Henderson 0610189297 i ' ,�z, . j °ll
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 M 7-18-2022
Signature ofCertt Well Contractor Dale
6.Is(are)the well(s): 2 Permanent or ❑Temporary Br signing this Jorm,I hereby certify that the well(s)was(were)constructed in accordance
With 15A NCAC 01C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo coPr ofthis record has been provided to the well owner.
If this is a mpair.till out known well construction in/bnnation and terplain the nature of the
repair under 421 reinarks section or on the back of this,iorm. 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 ifnecessary.
For nndtiple iniertion or non-water supple wells ONLY with the save construction,von can
submit one)orm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dfilcrent(example-3 u 200'and 2 cd100') construction to the following:
10.Static water level below top of casing: 20 Division of Water Resources,Information Processing Unit,
1f,wrer level is abate casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
1
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)
100 Method of test: RIG 24c.For Water Supply&In.iection Wells:
Also submit one copy of this form within 30 days of completion of
13h.Disinfection type: PILLS Amount: 20 well construction to the county health department of the county where
constructed.
Furst G W-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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