GW1-2022-10250_Well Construction - GW1_20221111

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 Contractor Name ft. ft.
4519-A
NC Well Contractor Certification Number 15.OUTER CASING`(for multi-case&wells)OR LINER if:a ticable-
FROM TO DIAMETER I THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 90 ft• 6 114 1' 1 #21 1 PVC
Company Name -.16.INNER CASING OR TUBING(geothermal closed-loop) -
20120117008 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. it. in.
List all applicable well permits(i.e.Counm,State. Variance.hyection,etc.)
it. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAI,
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I 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)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquilor Test ❑Stonnwater Drainage
ft. ft.
❑Eeperiniental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soittrock type,gnin size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 90 ft. OVER BURDEN
10-3-2022 90 ft 305 it• GRANITE
4.Date Well(s)Completed: Well fD#
ft. ft.
5a.Well Location:
Trellem Holdings LLC it. ft. ,
Facility/Owner Name Facility ID#(ifapplicable)
42 Trellem Trail Hendersonville, NC 28792 rt. rt.
Physical Address,City,and Zip 21.REMARKS intprirw4anPR-Y.009M UM
Henderson 9546399699 DWOMOG
County Parccl Identification No.(PIN)
51).Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(il'well field,one lat/long is sufficient)
46 N Wn AA 10-13-2022
Signature of Cent Well Contractor Dale
6.Is(are)the well(s): 2Permanent or ❑Temporary Br signing this Jornn,I hereby certijv that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.1200 Well C'onstniction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No coP),q/this record has been provided to the well owner.
ll'dus is a repair,fill out known well construction infbrnation and explain the nature of the
repair under#21 remarks section or on the back o/this forms 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
s.Number of wells constructed: construction details. You may also attach additional pages if necessary.
Fm uadliple injection or nnn-w•aler.supp/r wells ONLY with the scone construction,yrnt can
cnhmit one/nrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi(Jcreut(example-3@200'and 2C100') construction to the following:10.Static water level below top of casing: -
30 Division of Water Resources,Information Processing Unit,
l/water level is above rasing,use +" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For infection 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
(i.e.auger,rotary,cable,direct push,etc.) l
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 oftest:
15 RIG 24c.For Water Supply&Injection Wells:Also submit one copy of this form+t
within 30 days of completion of
13b.Disinfection type: PILLS Amount: 30 well construction to the county heaith I department of the county where
constructed. f
17u1111 GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013