GW1-2022-07728_Well Construction - GW1_20220819

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This firm can be used for single or multiple wells
1.Well Contractor information:
GARRETT CLYDE BANKS 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LiNERGcable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 76 ft- 6 1/8 ! in. #21 1 PVC
Company Name .16.iNNER CASING OR TUBiNG epthermal closed-loop)
22100110058 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Counh,State. Variance,/ejection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER .I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public R. ft. in.
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 fc. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Gxperimcntal 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#21 Remarks) 0 f` 76 ft OVER BURDEN
7-5-2022 76 f` 505 f` GRANITE
4.Date Well(s)Completed: WeII ID#
ft. ft.
5a.Well Location:
Chad Cabe
Facility/Owner Name Facility iD#(ifapplicable) ft. ft.
555 Patterson Road Hendersonville, NC 28792
Phvsical Address,City,and Zip
Henderson 9538927512 21.REMARKS
Countv Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwcll field,one tat/long is sufficient)
N N 7-12-2022
Signature of Cerlt Co Well ntractor Dale
6.is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,1 hereby terrify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo cope gfthis record has been provided to the well owner.
If this is a repair fill otd known well con.siraclion in.lbrmalion and explain the:nature ofthe
repair under#21 remarks section or on the back of'this.16mi. 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 nndriple injection or non-water.supp(-wells ONLY with the same construction,you can
submit one,form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 505 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Per multiple}-ells list all depths ifdi/ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 60 Division of Water Resources,Information Processing Unit,
l/ireaer level is above casing,use +" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY: Imaddition to sending the form to the address in
ROTARY 242 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:
7 RI G 24c.For Water Supply&Injection Wells:
,
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount 35 well construction to the county health
I department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013