GW1--03545_Well Construction - GW1_20230519

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT COLLIN BANKS T4:f`is
FROM TO DESCRIPTION
Well Contractor Name ft. ft. �
4519-A ft. ft.
NC Well Contractor Certification Number �IRttt G51#Ytr o veils'f3K'LfEl7:i°a ([a ' ; s
FROM TO DIAMETER TMCKNF,SS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 156 ft- 6 1/4 i #21 PVC
Company Name . ISiI`flyttrGS 'rK111)il eo_errnalpliedet
22100113000 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: fr. fr. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): . ,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public tt. ft. in
❑Geothermal(Heating/Cooling Supply) E IResidential Water Supply(single) ft. ft. in.
❑lndustriaUCommercial ❑Residential Water Supply(shared)
❑h FROM TO MATERTAL F.MPLACEMF.NT NfETROD&AMOUNT
Ti ation 0 et• 20 ft. Bentonite Pumped
Non-Water Supply well: ft. rt. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation kAY\rRT,.EA
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. fr.
❑Aquifer Test ❑Stormwater Drainage ft. ft. '
❑Experimental Technology El Subsidence Control
�t11)1i;11':IL•f��,_�,at'iacti'uldi'bb )feat�";iliie�8s5tirti!. � ^�F�
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiVroek type.Rmin Size etc.)
❑Geothermal (Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 156 ft. OVER BURDEN
4-18-2023 156 rt• 405 fr GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location: ft. fr. - `,.i�b fi
Gloria Garcia ft. ff. MAY
Facility/Owner Name Facility ID#(ifapplicable) 9�
ft, ft.
1315 Old Howard Gap Road Hendersonville, NC ..F
Lf r,
.
Physical Address,City, P ��e •. '. .. 5 +and Zip }�L�,. �y
a jCIYI.ARR�.�`.. �, Y f,.X ...,...
Henderson 9596949322 This 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)
fA
N W n AA 04/20/2023
Signature of CertiM Well Contractor Date
6.Is(are)the well(s): ❑�Permanent or ❑Temporary f f (were)constructed in accordance
B y^signing this form,1 hereby cent that the well(s)waslucre
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 i1'ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or [71No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain tire nature of the
repair render#21 remarks section or on the back ofthis/brm. 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: 1 construction details. You may also attach additional pages ifnecessary.
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:405 (ft.) 24a. For All Wells: Submit this form within 30 days of coinplction of well
For multiple wells list all depths ifdijferent(example-3 @)2 00'and 2(a,•100') construction to the following:
10.Statie water level below top of casing: 50 (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 thus 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
l
13a.Yield(gpm)4 Method of test- RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form i within 30 days of completion of
13b.Disinfection type: PILLS Amount: 35 well construction to the county health ldepartment of the county where
constructed. I '
Fong GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013