GW1--04503_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:
14 a�'f`,ATER=ZONltS . ..
GARRETT COLLIN BANKSP NF.> ..
FROM TO DESCRIPTION
Well Contractor Name ft. ft. 1
4519-A ft. ft. ,
NC Well Contractor Certification Number LSITOKEIVOA,SING,(fOeiiiiltt-casetl wells)OR LINER'fif tOlieAble)''i ,
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 70 ft. 6 1/4 ' in. #21 PVC
Company Name L6:1NNER,CASTNG;ORTC BING(ge thernisl.clused loop),X t._ `�:
055-2022-0690 FROM TO 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): •:i,17:.SCREEN , ('
Water Supply Well: i FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) l7Residential Water Supply(single) ft. ft. in.
d PP Y) PPY( g )
❑Industrial/Commercial ❑Residential Water Supply(shared) dg'GROtfI '' •` s,.°: `" �'� `` � �METHOD
°'
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft' •20 ft• Bentonite Pumped
Non-Water Supply Well:
ft. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: ft. H.
❑Aquifer Recharge ❑Groundwater Remediation 1;9;':SANO/GRAVEL PACM(if sppilealzle),
FROM TO MATERIAL _ EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
.20:DRlLLIRGYIOG.(attarchaddittaahsliectOfnecessart) ?. ; ,<%
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grstn size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 70 it OVER BURDEN
06-05-2023 70 .ft• 405 ft• GRANITE
4.Date Well(s)Completed: Well ID# 7- �,
ft. ft. l+°'„Fes_;. 3 t t t y 9r',,,,,.'',1,
5a.Well Location: ft. ft. ' •''it 'V, �z�P,,:
Ronald Stanley ft. ft. JUL 1 S 2023
Facility/Owner Name Facility 1Db(if applicable) ft. ft.
19 Stanley Ln, Hendersonville, 28739 ft• ft• ln,;,,.,l.;i:;:cn .'4$7.§ia,x
Physical Address,City,and Zip C+�`� <+�y
1t:IBMARKS' .> �a p'._
Henderson 9537793598 Well Was Self Certfied
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one la/long is sufficient)
N W 4-6 06/08/2023
Signature of Cent WellContractor Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,I hereby ca4ifi'that the well(s)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or 15A KCAL•02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or FINo 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 of this form. 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: I construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the state construction,you ran
submit one form. SUBMITTALiNSTUCTIONS
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 if different(example-3G200'and 2@ t00') construction to the following:
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 80 (ft)
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: 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
RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 2 Method of test:
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 Environment and Natural Resources—Division of Water Resources Revised August 2013