GW1-2022-07614_Well Construction - GW1_20220817

WELL CONSTRUCTION RECORD For Intemal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS �J4.wxlatlwg
FROM TO DESCRIPTION
Well Contractor Name
4519-A ft. ft.
NC Well Contractor Certification Number ?(5 t t1TEI#,t3tiSll*tax,f0"r',af ulfj?ase°11 ells"011e If a
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC + rr. ft• in.
Company Name al7ifslplNER,C iSIfV OR:Tl3B1]V0 eOtLerniat'cio4hd-loti'A �� ,;. � ' .:�.,r,
2022-001 20 FROM DIAMF;r'KR 'IHICKNFSS MATER1.41.
2.Well Construction Permit#: rt. ft. in.
List all applicable well permits(i.e.Counn.State,Yaiance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIANIE7'ER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑ cMunicipal/Publi ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) Ct. ft. in.
❑industrial/Commercial ❑Resldenfial Water Supply I (shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation ft. ft.
Non-Water Supply Well: 1't ft
❑Monitoring ❑Recovery
injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation $. e V 10" A"11'-
❑Aquifer Storage and Recovery ❑Salinity Barrier
FROM
rt. TO tr. MATERIAL EMPLACEMENT DIETHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal Closed Loop) 2t1bRt1t?O acl liddiiional sheets i1 necesary
( p) ❑Tracer FROM TO DESCRIPTION color•hardness soillrock tv a grain size,etc.)
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks)
4.Date Well(s)Completed: 06-24-22 Well 1D# 225 ft• 465 ft. GRANITE
ft. ft.
5a.Well Location: Lt• R. �• kp Lz y V k7--
ANDREW CARTER
Facility/Owner Name Facility ID#(if applicable)
24 GERTRUDE LANE ft. ft. I, >r� r rccoa=g Ufm
Physical Address,City,and Zip 2t.,ttEi19AR1Cb,•':? s ,r �- �., ' n ", >.' M211
BUNCOMBE 9618137656000 SET UP AND DRILLED DEEPER FROM 225 TO 465
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/secotids or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient)
N W 06-28-2022
Signature of Celtt Well Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary
By signing this ifrrm,1 herehr(erri&that the w�ehl(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: es or ENo copy o0his recard has been provided to the well owner.
Jfthis is a repair,fill out known well construction information and explain the nuture of due
repair under#21 remarks section or on the hack of this/i,rnr. 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 ifnecessary.
For multiple injection or non-w•ater.supply wells ONLY with the same construction,you can
submit one form. �f ,1 SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 225 TO 465 (ft.) 24a. For All Wells: Submit this forth within 30 days of completion of well
Far multiple welly list all depths ifd4jirent(example-3(a)100'and 2(a,,100') construction to the following:
10.Static water level below top of casing: 30 (ft-) Division of Water Resources,Information Processing Unit,
Ifwater level is above easing.use +" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY:i 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:
(Le.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
30 RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: 1
Also submit one copy of this form within 30 days of completion of
131).Disinfection type: PILLS Amount: 23 well construction to the county health department of the county where
constructed. I
Form G W-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013