GW1--06012_Well Construction - GW1_20230920

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT COLLIN BANKS 14.WATER,ZONES • „9 :. ., ,
FROM TO DESCRIPTION
Well Contractor Name ft. ft. I
4519-A ft. ft.
15.OUTER:CASING(for multi-cased'welis)OR LiNER itt a"Iicable)' k
NC Well Contractor Certification Number
P!
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 69 ft. 6 1/4 . in• #21 Pvc
Company Namc 16.;INNER CASING OR TUBING,(geothernlat closed-loop) ." ,
2022—oo2q 1 FROM TO DIAMETER THICKNESS MATERIAL
J
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): 17.SCREEN
"Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
ft. ft. in.(Heating/Cooling Supply) IJResidential Water Supply(sin le)❑Industrial/Commercial ❑Residential Water Supply(shared) GROUT a =€
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well: ft. ft.
OMonitoring ❑Recovery Cap Top with Bentonite Chips
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation '19.SAND/GRAVEL PACK(if applicable)
FROM TO - MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery ❑Salinity Barrier ft. ft.
DAquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary) ...' "
F,
❑Geothermal(Closed Loop) OTracer w FROM TO DESCRIPTION(color,hardness,sorock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 69 ft. OVER BURDEN
08/02/2023 69 ft• 405 f• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft. 7)
5a.Well Location: 4,,""' "'"^ A f 77
Debbie Sprinkle ft. ft. z ..� :.i �y ..,v
ft. ft.Facility/Owner Namc Facility ID#(if applicable) ft. ft. S E P r 2023
147 Brown Town Rd, Leicester 28748
ft. ft. ram+. UrSn
Physical Address,City,and Zip tft+vr n�
21•REMARKS "fi - 1 eit4i4172'
Buncombe 8790543006 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 W 08/08/2023
Signature of Cent Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form,1 hereby certh•that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or No 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 stature 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: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the seine construction,you can
submit one farm. ,1 SUBMITTAL INSTUCTIONS
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 ifdi//erent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:20 (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: 1
(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
4 RIG 24c.For WaterSupply&Injection Wells:
13a.Yield(gym) Method of test:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount 20 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