GW1--04501_Well Construction - GW1_20230713

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells '
1.Well Contractor Information:
GARRETT COLLIN BANKS 1 - m : wl.
FROM , TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number ss-1S`ilOTItitrikg t+tG..(f iEnii hicai iiii eil&),O(i GINEieffilaj plil'111e'►O
FROM TO - DIAMETER, THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 n• 128 it• 6 1/4 in. #21 Pvc •
Company Name MA tYF;4� SIN0:pft 'Ci31f719�c�ftternrsit`irctl tT-Juuii)" `"' `".
055-2023-0718 FROM '1'0 DIAMETER THICKNESS .IATM:R1.AI.
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): mSC13tI.)li 00 At, , '
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑MunicipallPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) E lResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) " . 'f"" M ' °"" ' 1;'' 77: 51*5" :\'
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft• 20 it Bentonite Pumped
Non-Water Supply Well:
ft. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: ft. ft.
DAquifer Recharge ❑GroundwaterRemediation M XIZ/.1 +YEIt141). t'(I apitliii+$1e}W ,'7,1: `'' ,
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
DAquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
r20: 1111X11501 lt'„(attaeh-itifdllianalxhe i ltiWeias"itk . w h r,* S
❑Geothermal(Closed Loop) ❑Tracer FROM . TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
DGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 128 ft• OVER BURDEN
5-22-2023 128 ft• 525 ft• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft. `�" ,'-- ,'i`t ,
Steve Melin/CMH Homes Inc ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. JUL ;, Z0Z3
940 Pace Road Hendersonville, NC 28792 ft. ft.
Physical Address,City,and Zip ;.Z,i.sltEII4Xkla auk Zvi;�'s :t'?). .0'`a -7
Henderson 9680918448 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 ladlong is sufficient)
N W k6 11/114Q1 5-24-2023
Signature of Celt Well Contractor Date
6.Ts(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby certify that the well(s)ryas(were)constructed in accordance
with 15A NCAC.02C.0100 nr 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or INo 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 back ofthis/bra. 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: 525 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 0000'and 2@100') construction to the following:
10.Static water level below top of casing: 1 80 (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) 1 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. 1 '
Forte GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013