GW1-2023-00620_Well Construction - GW1_20230105

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: I4
GARRETT CLYDE BANKS F4:31'ilGRNT
FRO TO DESCRIPTION
Well Contractor Name ft. ft. j
4519-A ft.
NC Well Contractor Certification Number
t5..0UTJ RCMtN'G for.'muld.cased>wells.Ok.LINElt ifs ItcaBte" ;
FROM TO DIAMF,TF.R THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 95 ft. 6 1/4 ' in. #21 PVC
Company Name ICANNER:C'A$IN,G,t)RTUBING eotheriarai'closed Ipd a
19100113117 FROM 10 DIAMFIF:R I'HICKNFSS MATFAI41
2.Well Construction Permit#:
ft. ft. to
List all applicable urll pennits(i.e.County,State,Variance,Injection,etc.)
ft. ft. j in.
3.Well Use(check well use): ff�3GRECl!L..
h..F. ..
Water Supply Well: FROM TO ITANFETER 1 SLOT STZE I THTCKNESS MATERIAL
ft. ft. in.'
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) FIResidential Water Supply(single) it. ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared)
'rtK'OROUT
pp y( FROM TO MATF.RTAL F.MPLACEMFNT METHOD&AMOUNT
❑irri ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft. ,
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation ;19.SgNDIGRPi1L.RAGK`pia ""za#ile
FROM TO MATERIAL EMPLACEMENT METHOD.>
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
2t1=1i12IY�LtNC=BOG attaeli addttiaunlslreefs iLnecessaty.�.... ... -------------'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soft/wkri a rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 95 ft. OVER BURDEN
11-14-2022 95 f` 205 ft. GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
CMH Homes INC
Facility/Owner Name Facility ID#(if applicable)
52 Moss Hill Dr. ft. ft.
Physical Address,City,and Zip 21:=izEMARldS- .... -: �i ., :• .t 1.•s.N .. n :e r t . ,.. --,--
Hendersonville 9681007455
County Pat-eel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N 11-18-2022
Sign t[ure of Certt Well Ceutractor Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this fenni,I herebv certify that the well ma s(were)constructed in accordance
ivith I SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No copy of this record has been provided to the well onmer.
If this is a repair•fill out knouv well construction information and explain the nature of the
repair under#21 remark,section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to proNide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit 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
For multiple wells list all depths ifdijf rent(example-3@000'and 2(a100D construction to the following:
I
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
If water 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
(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: RI G
24c.For Water Supply&Injection'Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 20 well construction to the county heallt i department of the county where
constructed.
4
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013