GW1--03552_Well Construction - GW1_20230519

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
i •
1.Well Contractor Information:
GARRETT COLLIN BANKS "
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft.
NC Well Contractor Certification Number 5 d111[l aiSll+t&'siiiiiiiiilti`�as diverts 171 aN tt "Ia
FROM TO DIAMETER I THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. 69 ft. 6 1/4 , i" #21 Pvc
Company Name G,<l1�INE.R: ASIt G.latll GiI91NO 'WW651" l,' Wiilk 000711MMSRR
055-2023-0087 FROM TO DIAMETER 'THICKNESS MATERIAL
2.Well Construction Permit#: ft. fr. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in,
3.Well Use(check well use): s7? ".
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal eatin /Coohn Supply) EIResidential Water Supply(sin(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) tR zx[1U 1 •s. � �� �
FROM TO MATERIAL �F.IITPLACEMENT METHOD&AMOUNT
❑lr; ation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
tt. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation9?SAT1f/CRA IaiPtCl 'llatbie � :
❑Aquifer Storage and Recovery Salinity Barrier FROM TO D•IATERIAL EMPLACEMENT atETHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology El Subsidence Control m,
rgfft-
❑Geothermal(Closed Loop) ❑Tracer TO DESCRIPTION color,hardness,soil/rock tv a rain size,etc.)
❑Geothermal Heatin Coolin Return) ❑Other(ex lain under#21 Remarks) 69 et• OVER BURDEN
4-24-2023 185 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft.
CJ
5a.Well Location: rt. ft.
Kevin Jones ft fr• MAY"
Facility/Owner Name Facility ID#(if applicable) ft. ft ".
16 Roland Jones Road Hendersonville, NC 28792
ra0 L,f'i::
Physical Address,City,and Zip .�•
Henderson 0611705832 This well was self certified
County Parcel Identification No.(PIN)
5b,Latitude and Longitude in degrees/minuteslsecouds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
N W 5-1-2023
Signature of Certr Well 6Contraetor Date
6.is(are)the well(s): ❑O Permanent or ❑Temporary
By signing this form,1 berehv certijy�their the well(s)was(were)constructed in accordance
ivith 15A NCAC 02C.0100 nr 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No 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 remarks section or on the flack of this farm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
$.Number of wells constructed: 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: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ij'dilfcrent(example-3 dt 00'and 2(al00') construction to the following:
10.Static water level below top of casing: 20 (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 Injection 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: constriction 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) 100 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• 25 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