GW1-2023-02858_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 rE x>nrt s
FROM TO DESCRIPTION "
ft
Well Contractor Name ft. ft.
4519—A ft.
NC Well Contractor Certification Number
15x()Ii fgK3ASItYG.'foritti-c�svelfs"ORi iNRIF'ifa"`'Iicabte M-V0 :
FROM TO DIAMETER THICKNESS 11fATERiAi.
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 81 ft. 6 1/4 in #21 PVC
Company Name MCI NNEt2 C'SING CiW7`091RGz""eG het titaC�losed(4 .., _
19100112492 FROM 1'O DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in
3.Well Use(check well use): R17.:SCREEIl1.x ;i aa, r, >x'"V, i s
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS I 11IATERi.AL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in.
❑IndustriaUCommercial ❑Residential Water Supply
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT�
❑irri ation
Non-Water Supply Well: ft' 20 ft- Bentonite Pumped
rc. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation 49'4SANDIGRAVECTAGK"d3
❑Aquifer Storage and Recovery ❑Salinity Barrier
FROM ft. TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft
❑Experimental Technology ❑Subsidence Control
Al"I2II9L`lisIG19G,i I iiiii,addihauntaheets ifiiecessar"r�s `a "
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION ealar,hardness•soiUrmk type,grain size,eye.)
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 ft- 81 ft. OVER BURDEN
3-31-2023 81 ft 405 fr ,GRANLTE-
4.Date Wells)Completed: Well ID# ft. ft. i a ' .z. Wv
5a.Well Location:
rt. rt.
CMH HOMES INC ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft, ft.
ra9't„�;r•r-•
197 MOSS HILL DRIVE HENDERSONVILLE, NC 28792 It. ft.
Physical Address,City,and Zip .2•( EMA12fC5„>> " Est .a', �,', '
HENDERSON 9651 105702 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 lat/long is sufficient)
N W 01 A n AA 4-5-2023
Signature of Certl Well Contrdctor Date
6.is(are)the well(s): OPermanent or ❑Temporary
By signing this from,1 herehv certify that the well(s)was(rvere)constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 N ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy of this 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 remark section or on the backofthis•/arm• 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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-hater supply wells ONLY with the satne construction,you can
submit onefm•m. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iit'di fereni(erample-3 dl 00'and 2(a,100') construction to the following:
10.Static water level below top of casing: 50 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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.e.auger,rotary,cable,direct push,etc.) j
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 35 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Euviroument and Natural Resources—Division of Water Resources Revised August 2013