GW1-2022-09441_Well Construction - GW1_20221017

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This Ibrm can be used for single or multiple wells
I.Well Contractor Information:
14.WATER ZONES $' I
GARRETT CLYDE BANKS FROM DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft. i
NC Wall Contractor Certification Number 15.OUTER CASING(for multi-eased'wells)'OR LINER(if'a licable)
FROM TO DIAMETER I THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft' 31 ft- 6 1/8 1 in #21 1 PVC
Company Name 16.INNER CASING OR TUBING eotbermal closed-too
22120106606 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State, Variance,hyection,etc.) ft. ft. 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
❑Geothernial Heating/Cooling-Supply) ElResidential Water Supply ft. ft. in.
( c o PP Y) PP Y
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑h1'igation 0 ft. 20 ft. Bentonite Pumped
Nor-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG.(attach additional sheets if necessa
❑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. 31 rt. OVER BURDEN
8-25-2022 31 ft• 125 ft• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Patricia Garrett "��' -
f[. ft.
Facility/Owner Name. Facility ID#(ifapplicable) ft. ft. j
Lovdia Lane Hendersonville, NC 28792 ft.
Phvsical Address,City,and Zip Unit
21.REMARKS
Henderson 9526919087
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one tat/long is sufficient)
N W 8-30-2022
Signature ofCerlt Well Contractor Dale
6.1T(are)the well(s): ❑O Permanent or ❑Temporary By signing this fonn,i hereby certify that the well(s)was(were)constructed in accordance
with 15A 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 ONo cop),gfthis record has been provided to the well owner.
lflhis is a repair,fill out known well con.siruction information and arplain Nye nature of'the
repoir under#21 remarks section or on the back g1'thisfbnm. 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 same construction,you can
submit are farm. SUBMITTAL INSTUCTIONS
9.'fotal well depth below land surface: 125 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For mrultiple n•ells list all depths j1'c1i(ferent(exanhple-3@200'and 2 a7100') construction t0 the following:
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
If nnter level is above 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,lUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(-pm) 24c.For Water Supply&Injection,Wells:
15 Method of test: RIG
Also submit one copy of this fonn within 30 days of completion of
13b.Disinfection type: PILLS Amount: 20 well construction to the county health department of the county where
constructed.
Form G W-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013