GW1-2022-10251_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: I'
GARRETT CLYDE BANKS 14.
FROM ERZrO
RODI "I'O DESCRIPTION
Well C'onwaclor Name
ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER(if a Gcable
FROM TO DIAMETER !;, THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft' 73 ft- 6 1/4 I " #21 1 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
22100114063 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable Hrll permits(i.e.Counhy State. Variance.hyection,etc.)
ft. ft. in.
i
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply ft. tt. in.
d PP Y) PP Y
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[]Irrigation 0 rc. 20 rr• Bentonite Pumped
Non-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 tt. ft.
❑Aquifer Tcst ❑Stonnwater Drainage
ft. rt.
❑Fxperimcntal Technology ❑Subsidence Control
2(L DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 73 ft' OVER BURDEN
10-4-2022 73 ft• 205 rt• q GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Thomas McMinn ft. ft. ,
Facility/Os+net Name Facility ID#(ifapplicablc)
302 Evans Road Hendersonville, NC 28792 ft. ft.
I'hvsical Address,City,and Zip _21.REMARKS
Henderson 9546953230m
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 NnAA 10-11-2022
Signature of Cer1 Well Contractor Dale
6.Is(are)the well(s): OPermanent or ❑Temporary
Br signing this Jonn,1 hereby certiJv that the wel/(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC�02C.01110 Well Construction Standards and their a
7.Is this a repair to an existing well: ❑Yes or ElNo copy gf1his reeord has heen provided to the well owner.
this is a repair.fill out known well construction inlnraation and evplain the nature gl'the
repair wider 41/reinarAs section or on the back o/'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 ifnecessary.
For multiple injection or non-water supphv wells ONLY with the sane construc•Non,you can
suhmil one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 205 (ft.) 24a, For All Wells: Submit this form within 30 days of completion of well
I'm multiple wells list all depths it dt(Jerent(example-3 200'and 1G100') construction to the following:
i
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
//hater level is above casing,use"+.' 1617 Mail Service Ce ter,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
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ROTARY construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) I -
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cen I ter,Raleigh,NC 27699-1636
13a.Yield(gpm)
12 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this fomml 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 GW-I North Carolina Department of Environment and Natural Resources—Division or Water Resources Revised August 2013
`t
f