GW1-2022-10249_Well Construction - GW1_20221111

WELL CONSTRUCTION RECORD For Internal Use ONLY.
This l6rm nun be used for single or multiple wells j
1.Well Contractor Information: I
r
14.WATERZONES
GARRETT CLYDE BANKS l I
FROM 'I'O DESCRIPTION
Well Connector Name ft. ft. G 1
4519-A ft. ft. II 4
NC Well Contractor Certification Number 15.OUTER CASING.(forlti-cased wells)OR LINER(if.a Gcable
FROM mu
TO DIAMETER i.. THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 142 ft- 6 1/4 I '" 1 #21 1 PVC
Company Name .16.INNER CASING OR TUBING(geothermal closed-loop)
22100111969 FROM TO DIAMETER THICKNESS MATERIAL
?.Well Construction Permit#: tc. ft. i in.
1.is-r till applicable well permits(i.e.County,State. Variance,11yection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER ( SLOTSIZE THICKNESS MATERIAL
ft. ft. in.
❑A_ri C Lt l l u rat ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ElResidemial Water Supply(single) ft. 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:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑ FROM TO Salinity Barrier ft. ft. MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
06xperiniental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillnek type,gnin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 142 ft. OVER BURDEN
8_9_ O22 142 ft- 325 ft- GRANITE
4.Date Well(s)Completed: Well TD#
rc. fr. i
5a.Well Location:
William Hoots ft. ft. '
Faci:iiy/Ginner Name Facility ID#(ifapplicable) ft. ft.
73 Honey Lane Hendersonville, NC 28792 ft. ft. tt~xf,�Pfx3o041 UM
Pin'sical Address.City,and Zip 21.REMARKS
Henderson 9690800741
('ounl.\ Parcel Identification No.(PIN)
i
51).Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
l il'svell field,one fat/long is sufficient)
N `1 10-13-2022
Signature oJ`Cer?)it4WeII Contractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary Br signing this form,1 hereby cart4' than the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy gf1his record has been provided to the well owner.
Ifthis is a repair,fill out knonn well construction injonnaiion and explain the nature of the
repair under 421 remarks section or on the back oj`this form. 23.Site diagram or additional well ldetails:
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.
fire uudriplc injection or nun-water supply wells ONLY with the sate construction,ynu ran
�uhorit one f ri n, SUBMITTAL INSTUCTIONS
9.'total well depth below land surface: 325 (ft.) 24a. For All Wells: Submit this ''form within 30 days of completion of well
Pot mulriplc wells list all depths i/'dilkrcnt("example-3@200'and 2L100') construction to the following:
10.Static water level below top of casing•40 (ft.) Division of Water Resources,Information Processing Unit,
10 awr leycl is above casing,use..+" 1617 Mail Service Cc I nter,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:
l x.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) 5 Method of test: RIG 24c.For Water Supply&Injection(Wells:
Also submit one copy of this form within 30 days ofcompletion of
PILLS well construction to the county healthldepartment of the county where
13b.Disinfection type: Amount: 3O l
constructed.
Furor;G W-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013