GW1-2023-01985_Well Construction - GW1_20230227

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS FRO51 TO DESCRIPTION
Well Contractor Name ft. ft. I
4519-A ft. ft.
NC Well Contractor Certification Number �1 5 0 OT it MOM I N G;(fiQrWA-"6'a i io-owu"FNgiefir"i
FROM TO I DIAMTER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft' 34 ft- 6 1/4 1 #21 PVC
Company Name 'faIN06 fi4iii4l'iftwiak
1*0 DIAMETER THICKNESS
2.Well Construction Permit#: 21100116699 FROM ft. ft. in. 20S 9 I 121.21AL
List all applicable well permits(i.e.County,State,Variance,injection,etc.) ft. ft. in.
3.Well Use(check well use): � 7.�SCR
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
ElAgricultural DMunicipal/Public ft. ft.
DGeothermal(Heating/Cooling Supply) EIResidential Water Supply(single) in.
�
'GRO g
01ndustrial/Conamercial DResidential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&A.%fOU.W
01nigation 0 ft' 20 ft- Bentonite Pumped
Non-Water Supply Well:
OMonitoring ORecovery
Injection Well:
OAquifer Recharge CGroundwater Remediation 1.19v,5ANDlGPAVR
DAquifer Storage and Recovery ElSalinityl3arrier FROM ft. To MATERIAL ENIPLACEMUNT 51ETHOD
DAquifer Test OStormwaterDrainage
ft. ft.
OExperimental Technology ElSubsidence Control
DGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color.hardness,sailtrock type.grain size,etc.)
DGeothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 0 ft- 34 ft. OVER BURDEN
4.Date Well(s)Completed: 01-03-2023 Well ID4 34 165 ft GRANITE
5a.Well Location:
Charles Wix
Facility/Owner Name Facility 1D#(ifapplicable) ft. ft. LL71 2023
112 McGraw Lane Lot t Hendersonville, NC 28792 ft. ft.
Physical Address,City,and Zip 7-
,','2 1-,R E?VI*R WS_IW!�
Henderson 9578524371 Well Was Self Certified
County Parcel Identification No.(PIN)
5b:Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(if well field,one lattlong is sufficient)
N W n AA 01/05/2023
dAur-V of
SignatL3c_ofCcrU'l1K Well Contractor Date
6.Is(are)the well(s): [OPermanent or OTemporary
By signing this form,I hereby certify that the well(s)ivas(were)constructed in accordance
with 15A JVCAC 02C.0100 or 15A NCAC 02:117.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or E]No copy ofthis record has been prorided to the well owner.
If this is a rtepair,fill out knout well construction it formation and explain the nature of the
repair wider#21 remitrAzz;section or on the back-qj'ihisforny. 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.
For multiple injection or non-water supply wells ONLY with the same construction,you cat?
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 165
-(ft.) 24a. For All Wells: Submit this form within 30 days of complction of well
For multiple wells list all depths if*&Jferent(example-3(ai)200'anti 2(a,100) construction to the following:
10.Static water level below top of casing: 30 Division of Water Resources,1. Information Processing Unit,
If wafer level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY: lo 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
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground; Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cenier Raleigh,NC 27699-1636
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13a.Yield(gpm) 6 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: PILLS Ainoiint: 20 well construction to the county health department of the county where
constructed.
FormGW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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