GW1-2023-02774_Well Construction - GW1_20230417

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT COLLIN BANKS FROM
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number dS•fJUTE12 G�AS(tYGr for-isitti=casr7 w11 "OItxLlhER if I[cabte
FROM TO I DIAMETER THICKNESS MATF.RIAI.
CLYDE SAWYERS & SON WELL & PUMP INC +1 It. 72 ft- 6 1/4 i" #21 PVC
Company Name �16 11SINER CitST1VCx.0ItiT,l`1tilNf7 cot ermetclos`44`1��
2022-00454 FROM DIAMETER 'THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(I.e.Coungt State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): E7.SCREENS -F
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
tt.
❑Agricultural ❑Municipal/Public ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) sl8 tsR{)l1T
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑h,; ation 0 ft' 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. rt. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation IA::SAISD%GRAX!EL�,AGK'il a`llcab5e 1 � _.
❑Aquifer Storage and Recovery El Salinity Barrier FROM ft. ft.TO MATERIAL E51PLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
;;�ZO:�DRIL5ti1NC1;U+�fa&acti-add[hancttsheetsif'�riecesstlrv�s�.�':[ "�'�
❑Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTION color,hardness,soiVrmk type. rein size.etc.
[]Geothermal Heatin Coolin Return ❑Other(e)Tlain under#21 Remarks 0 ft. 72 ft. OVER BURDEN
3-15-2023 72 fr• 465 rt• GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location: et. rt. 4, '
Miller/ Lamplighter Ridge --
Facility/Owner Name Facility ID#(if applicable) 1
ft. ft. APR e
2023
7 Hubbard Lane Candler, NC 28715 ft. ft. ;r'-.3;. ,
:-1 t'3 I
Physical Address,City,and Zip 21:REMARKS y '
Buncombe 9618232036 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 lat/long is sufficient)
N WA 03/16/2023
Signature of certu Well Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this form,l berebv certify that the well(s)was(were)constructed in accordance
with 1SA NCAC.02C.0100 or 1 SA NCAC 02C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy of this record has been provided to the well owner.
If this is a repair,fdl out known well construction information and explain the nature of the
repair under 921 remarla•section or on the back oJ'11ds Jbrm. 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: construction details. You may also attach additional pages ifnecessary.
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: 465 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list u11 depths iJ'different(es dlamyle-3 00'and 2(a100� construction to the following:
10.Static water level below top of casing: 60 (ft-) Division of Water Resources,Information Processing Unit,
If water level is above rasing.use"+•' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 246.For Iniection 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: constnuction 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) 12 Method of test: RIG 24c.For Water Supply 3r Injection Wells:
PILLS Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: Amount: 35 well construction to the county health department of the county where
constructed.
Foria GW-1 North Carolina Department of Euvuonment and Natural Resources—Division of Water Resources Revised August 2013