GW1-2023-02855_Well Construction - GW1_20230418

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT COLLIN BANKS FROM TO DESCRIPTION
Well Contractor Name ft. fr.
4519-A ft.
NC Well Contractor Certification Number t5OUTEti,("115IltCs.formnlHtl;tivetts`OK 131NER,if."a chh �.
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. 99 ft. 6 1/4 i" #21 PVC
Company Name 4,16 1NNEli"Ca9iNGo[iTi)s1NG cufliernintcloSed-to"' ;.: 'i
FROM . TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 055-2022-0422
in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in,
3.Well Use(check well use): �t? SGREGNnw., �� x fix " '
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
in.
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) EIResidential Water Supply(sin(single)
❑lndustrial/Commercial ❑Residential Water Supply(Shared) 1R;s'Gttl 1JT ,x k ,v<, �:"' € �
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
01ni ation 0 et. 20 ft- Bentonite Pumped
Non-Water Supply Well:
rc. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation .I9 SAND/41tA'T?L)V PAt K'.t•a"lla+b7e h. 4w
FRO51 TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
[t. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
4,20}711tIC:I;;NGIT:0 ditionaT'"she�tsifn"ecessar`v'�
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sollfxwk type. rain size,etc.)
❑Geothermal (Heating/Cooling Return 00ther(explain under 921 Remarks) 0 ft 99 fr OVER BURDEN
3-1-2023 99 ft 365 ft GRANITE
4.Date Well(s)Completed: Well ID# _
5a.Well Location: ft. ft. •.,-x ,;% i a s
Anner Morales ft. fr. APR 7
73
Facility/Owner Name Facility ID#(if applicable) ! _
942 Pleasant Grove Road Hendersonville, NC 28792 rt. ft. ��"•�°:5771
Physical Address,City,and Zip2iR1
Henderson 9528735017 Well Was Self Certified
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell Geld,one ladlong is sufficient)
N � ,O-A 03/01/2023
Signature of Certt Well Contractor Date
6.is(are)the well(s): 2Permanent or ❑Temporary By signing this farm,I herehv certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 N ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No copy of tins record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of 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
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple 6yeetion or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface• 365 (ft.) 24a. For All. Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iif'differew(example-3 tit 00'and 2(a100� construction to the following:
10.Static water level below top of casing:40 (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 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.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) 12 Method of test: RIG
24c.For Water Supply&Injection Wells:
Also submit one copy of this form''within 30 days ofcompletion of
PILLS
13b.Disinfection type: Amount: 35 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division ofWater Resotuces Revised August 2013