GW1-2023-02860_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 xF�:�M�rlRu►l ��f�Ss� � ��
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519—A ft. ft.
NC Well Contractor Certification Number
aW 60 ri�fc,c' ilw.t; forniiiii ased:tietts"arc Grrr R"i s csiile ".>
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 170 ft. 6 1/4 #21 PVC
Company Name1G<IIVNER4CiiSf"Cr t}q TtI133NG,"eofhCtmet:ctosed f$U :' >„ a
19100112497 FROM 1'O DIAMETER 'THICKNESS.W MATERIAL
2.Well Construction Permit#: ft. fr. in.
List all applicable well permits(i.e.CounV.State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): f7SCR EENY
Water Supply Well: FROM I TO DIAMETER SLOT SIZE THICKNESS I 11IATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal (Heating/Cooling Supply) OResidential Water SuPP1Y(single) ft ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) r1R GROUT--------
FROM TO MATERIAL EMPLACEMENT MF.THOII&AMOUNT
011Ti ation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply well: ft. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: t't. ft.
❑Aquifer Recharge ❑GroundwaterRemediation x19:SA1�DIGRACL�kAG1 ` .a""'Iicableuz ,.... Kz
❑Aquifer Storage and Recovery ❑Salinity Barrier
FROM
ft. TO ft. MATERIAL EDIPLACEME_NT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
�20r?DR1T;�Nt;�I;gG.attach=sddrtioaal, fs it, ssutv'�=VM,.R�� `�,
[]Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardness soil/rock type. ram size,etc.)
❑Geothermal Heating/Coolin Return ❑Other(explain under#21 Remarks) 0 ft. 70 ft. OVER BURDEN
3-29-2023 70 ft- 505 ft- �GRANIT-E
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: >_
ft. ft. n.
CMH HOMES INC rt. fr. 2023
Facility/Owner Name Facility ID#(if applicable) ft. ft. if:i�i'r L_,.:•
243 MOSS HILL DRIVE HENDERSONVILLE NC 28792
Physical Address,City,and Zip 2IVROMWRFK9 0k� m'
HENDERSON 9681107731 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 laUlong is sufficient)
N Yn AA 3-30-2023
Signature of Certl Well Contractor W It Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this firm,I herebv certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 ar 15A NCAC 02C.0200;*11 Comchwction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided to the well owner.
If this is a repair,fill out knouw well construction infurniatian and explain the nature of the
repair Larder 921 remarb section or on the back oJthis 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: 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: 505 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-9 d 00'and 2(w,100') construction to the following:
10.Static water level below top of casing: 180 (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.e.auger,rotary,cable,direct push,etc.)
Dhision of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 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: 35 well construction to the county health department of the county where
constructed.
Forst GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013