GW1--04505_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 la's'ATE'�zoxtm o` va s, ..
FROM TO , DESCRIPTION
Well Contractor Name ft. ft. I '
4519-A ft. ft.
NC Well Contractor Certification Number 5,i'OUTEICGMi14fi(for tult3 ladUlli)MLiNER'.(tf aiplicalile) 4?",a; W
FROM TO DIAMETER THICKNESS MATERIAL.
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 130 ft. 6 1/4 , in. #21 PVC
Company Name aafiNNEICiGASINC4101.411111NOTIkeifiliiiiiiirilaM14filir Tamikv' `
055-2023-0174 FROM To DIAMETER THICKNESS SIATERIAI.
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): ,1t7ACRBE .," .. .,f ; .k , N...V F W SS
Water Supply Well: FROM TO DIAMETER SLOT SIZE , THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑MmticipallPublic
❑Geothermal(Heating/Cooling Supply) ©Residential Water Supply(single) ft. ft. in.
❑lndustriallCommercial ❑Residential Water Supply(shared) 18 GROUTS � „ �''" ` # ' fix.' .. 6 t''
FROM TO MATERIAL EMPLACEMENT MF.I'HOD 8 AMOUNT
❑Irrigation 0 ft• 20 ft• Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft. Cap Top with Bentonite Chips
Injection Well: It. ft-
❑Aquifer Recharge ❑Groundwater Remediation 19ISANO/GRAVEL EACK°tii;alipliea6le) M, 't. cs: k. '
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage •
ft. ft.
❑Experimental Technology El Subsidence Control
'n2014)RILLdN6 TiOatite eti add)ttoriitrilieets`inkessari) `` ..
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑other(explain under#21 Remarks) 0 ft• 130 ft• OVER BURDEN
5-29-2023 130 ft• 305 ft• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft. l,'`- ,( u- ! '�1...,7-'"
5a.Well Location: ft. ft. a . a.. -•-.;/
Billy's Modular& Mobile Cont ft. ft. JUL I ZU13
Facility/Owner Name Facility ID#(if applicable) ft, ft.
1 Pr i.PF:ii:Jail ,')r.-... A,s, ° cci :-
1783 St Pawls Road Hendersonville, NC 28792 ft. Ii-goft. C'e'i,v,thn cv.:
Physical Address,City,and Zip ,121PRE4lARIC5 e`g. ; ;ac s s." i .
Henderson 0602523239 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 1at/long is sufficient)
N W 06/01/2023
Signature ofCerh Well Contractor Date
6.Ts(are)the well(s): OPermanent or ❑Temporary By signing this fenm,1 hereby certify that the wells,) was(were)constructed in accordance
with 15.4 NCAC 02C.0100 nr 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or hJNo 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 hack 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
S.Number of wells constructed: 1 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: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if(Wren'(example-3 d 00'and 2(000) construction to the following: ,
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If linter 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) 5 Method of test:
Also submit one copy of this form within 30 days of completion of
PILLS
13b.Disinfection type: Amount 30 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