GW1--06092_Well Construction - GW1_20230921

WELL CONSTRUCTION RECORD For Internal Use ONLY: '
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT COLLIN BANKS lta��} nitcz NEE . V 'gym,, .:�:
FROM TO DESCRIPTION
Well Contractor Name ft, ft.
4519-A ft. ft. . I
NC Well Contractor Certification Number 15..`OUiEERtGASi1?fii.(fai4m0Iti•cits`6I tls'':ORLINPt2(lfaap Cs1itN} ''-'-' x
FROM TO DIAMETF.RI THICKNESS MATERIAL.
CLYDE SAWYERS & SON WELL & PUMP INC +1 a. 32 ft. 6 1/4 I I in. #21 l PVC
Company Name i61NNERIVASING0ORTiMING, eplltermelSclo`sed=t00p)` ..
OSS-2023-0306 FROM 'r0 DIAMETER 'rIIICKNESS MA'I'ERI.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): S RgE1r ,6:',.'' �7
Water Supply Well: FROM . TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑MunicipallPublic
❑Geothermal(Heating/Cooling Supply) EResidential Water Supply fL ft in.
(H g/ g pp y) pp y(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) n18'GR()U'C ' �',',toma at
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hTigation 0 ft' 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft. Cap Top with Bentonite Chips
Injection Well: ft. fL
N
❑Aquifer Recharge ❑Groundwater Remediation fl"9:SAND/GNAt? )rl? GKt(ifa"ppliiit)leiNtMV~ ',` ' V
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
tt. ft.
❑Aquifer Test ❑Stormwater Drainage '
ft. ft.
❑Experimental Technology ❑Subsidence Control ,,
2i1.DRIt",T�I1VG'rociraliacti adaitta66-Wis f iTiiisiiv .
❑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. 32 ft. OVER BURDEN
4.Date Well(s)Completed: 7-5-2023 Well ID# 32 ft. 605 ft. GRANITE
It. ft.
5a.Well Location: ft. ft. •
i
STEPHANIE FLORES ft. ft. 1 •t&g.._ _.i tz a,...
Facility/Owner Name Facility ID//(if applicable) ft. ft. SEP 2 I 20Z3
162 MAYBIN ROAD HENDERSONVILLE, NC 28792 ft. ft.
Physical Address,City,and Zip t' -.. �. I,tI+.A
HENDERSON tam -rTaal�sa„„;� :�. .ln..��� �.. � ;
Well was self certified 4 4
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) C
N `i, givvotki
7-6-2023
Signature of Certr well Contractor of Certl Well Contractor ' Date
6.Ts(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby certify that die well(s)was(were)constructed in accordance
with ISA NCAC.02C.0100 nr 15A NCAG 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo copy of this record has been provided to the well ounicr.
i
If this is a nnair,fill out known well construction information and explain the nature of the
repair under II21 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
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or none-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 605 (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(di 00'and 24 100') construction to the following: I1
10.Static water level below top of casing: 1 60 (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: 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
1 RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 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 healtl�i department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013