GW1-2022-10254_Well Construction - GW1_20221111

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This l6 nr can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS FR:WATER ZONES „ N
FROM To DESCRIPTION
Well Contractor Name
ft. ft. I
4519-A
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. 50 ft. 6 1/4 'n #21 1 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
21100115881 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt. in.
List all applicable trell permits(i.e.County.State.Variance,hyection.etc.)
ft. fL in.
I
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER i SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Aericultw'al ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply ft. ft. in.
PP Y) PP Y
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri`-ation 0 it• 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licablc
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stonrrwatcr Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG'attach additionafsheets if necessar
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiltrock type,grain sae,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 50 ft. OVER BURDEN
9-28-2022 50 it 705 it GRANITE
�.Date Well(s)Completed: Well ID#
ft. it.
5a.Well Location:
Richard Mellert Trustee tt. ft.
facility/Owner Name Facility ID#(if applicable) ft. ft.
140 Sapata Trail Hendersonville, NC 28792 rt. rt. NOV i
Physical Address,City,and Zip 21.REMARKS *' swim unit
Henderson 9546392662
Count. Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
5b.yell field,one d long is rude ient)
N W, 10-12-2022
C r III, V QM&
Signature ofCertt Well Contractor Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,I herebv certi&that the well(s)urns(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAe 02C.0200 Well Consimction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy gf1his record has been provided to the well owner.
//this is a repair,fill oul known well construction iniimnation and erplain the nature of the I
repair under 421 remarks section or on the back of this./brm. 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.
l iu utabiplc iujecliun ur nun-water supp/v wel/s ONLY with the sane construction,von can
SUBMITTAL INSTUCTIONS
9.'total well depth below land surface: 705 (ft.) 24a. For All Wells: Submit this farm within 30 days of completion of well
Fur multiple trells list all depths ifahlferent(example-3@200'and 2@100') construction to the following:
80 Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: (ft.)
It wcter level is above casing.use"+- 1617 Mail Service Cc Iter,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.e.;weer,rotary,cable,direct push,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&Injection :
13a.Yield(gpm) 5 Method of test: RIG Wells
Also submit one copy of this formt Within 30 days of completion of
13b.Disinfection type: PILLS Amount: 35 well construction to the county health`department of the county where
constructed. E
Fong GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013