GW1-2022-09529_Well Construction - GW1_20221017

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
14.WATER ZONES
GARRETT CLYDE BANKS
FROM TO DESCRIPTION
Well Connector Name ft. ft.
4519—A
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased+wells)OR LINER(if a licable
FROM[ TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 52 ft- 6 1/8 , #21 PVC
Company Name 6.INNER CASING OR TUBING eothermal closed400 .
22100103413 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. +1-
in•
List all applicable ivell permits(i.e.Count),,State.Variance,Injection,etc.) ft in
3.Well Use(check well use): 17.SCREEN r
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. fL in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) IResidential Water SuPP1Y(single) f. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquiter Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable).
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
El Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessar
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sail/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 52 ft. OVER BURDEN
8-17-2022 52 ft• 165 ft• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Richard Mikos
Facility/Owner Name Facility ID#(if applicable)
770 Hillside Lane Hendersonville, NC 28792 .,r .A
ft. ft. 7,
Physical Address,City,and Zip 21.REMARKS`.
Henderson 9559502027
County Parcel Identification No.(PIN) 'JL:
5b,Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(it'well Feld,one hit/long is sufficient)
N 8-23-2022
Signature ot'Certitl<Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary Br signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constaiction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy gflhis record has been provided to the well owner.
lf1his is it repair,Jill out known well con.sintelion infrirnmtion and explain the nature of the
repair under 921 remarks section or on the back gl'this form. 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 nmdtiple injection or non-water supply wells ONLY with the sane construction,you can
submit one•form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 165 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i/'d?ftremt(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing: 30 Division of Water Resources,Information Processing Unit,
If uarer 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
13a.Yield(gpm) 20 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this forrn within 30 days of completion of
13b.Disinfection type: PILLS Amount: 20 well construction to the county health department of the county where
constructed. i
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013