GW1-2022-09443_Well Construction - GW1_20221017

WELL CONSTRUCTION RECORD For Internal Use 0NLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
GARRETT CLYDE BANKS 14.WATER ZONEs S
FROM '1'O DESCRIPTION
Well Contractor Name
4519-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-casediwells)OR LINER(if a Ocable)
FROM TO DIAMETER I THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 41 ft 6 1/8 i #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
22100103480 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State.Variance,h jection,etc.)
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. ft.❑A gricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑h'rigation 0 f. 20 ft Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer•Test ❑Stontrwatcr 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,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) 0 ft. 1 ft. OVER BURDEN
8-24-2022 41 ft 605 ft GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: [t. ft. _
Mary Gichuni ft. ft. �, :
a 4v
Facility/Owner Name Facility ID#(ifapplicable)
124 Shady Oak Lane Hendersonville, NC 28792 rt rt
PIIVSII'8I Address,City,and Zip 21.REMARKS ifrf;i i;�; `�1"f"^^•^•.^.'�'.� 1 it
Henderson 9548493839 <;. 0G
County Parccl Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(i f we I I field,one lat/long is sufficient)
N N (lio 9-8-2022
Signature ofCertr Well Contractor Date
6.Is(are)the well(s): EPermanent or ❑Temporary By signing this form,1 hereby certify that the we/l(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC,,02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo cony gfthis record has been provided to the well owner.
k this is a repair,,jill out known well construction brJbrunation and mplain the nature ofthe
repair under#21 remarks section of on the back o/'this•.1bnn. 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 ifnecessary.
For multiple injection or non-water supph wells ONLY with the scone construction,ynu can
.submit nnr Jnnn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 605 -(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i/'diftrent(example-3 rt 200'and 2G100') construction to the following:
10.Static water level below top of casing: 50 (ft.) Division of Water Resources,Information Processing Unit,
I!water level is above rasing,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.:ntger,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) 1.5 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: 35 well construction to the county health department of the county where
constructed. l
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013