GW1--06024_Well Construction - GW1_20230920

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT COLLIN BANKS stowATritzonszetaF., - - I:IPA „ - `
FROM . TO , DESCRIPTION
Well Contractor Name ft. ft.
4519-A . ft. ft. I
NC WellContlactorCertificationNumber lSt)U'LERICSLI[fa(for'mWd eas d+i"rCtls}:ORITIVER(11»"applfcablGj
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt• 72 ft. 6 1/4 I #21 PVC
Company Name i64iNNel2 GAS(lYfk legiiitiNO(�eoflti"rairllicltised-too(i) " �41M E
2023-00163 FROM •r0 imamrI'IaR THICKNESS MA'1'ERIAI,
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): W17All('.REEIYF I .: f 44tI MI 11.1%
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS , MATERIAL
❑Agricultural ❑Mucipal/Publie ft. ft. in.'
ni 1
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single)
ft. ft. in.!
� � g PPY) PPY( g
❑Industrial/Colnmercial ❑Residential Water Supply(shared) NI ORO T ` 1 �al.PA�. ; t ' , `� `�' `
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑h•rigation 0 ft' 20 ft• Bentonite Pumped
Non-Water Supply Well: .
•
❑Monitoring ❑Recovery lt. ft. Cap Top with Bentonite Chips
Injection Well: ft. ft. .
❑AquiferRecharge ❑GroundwaterRemediation 41191SAN111GRits1?E1,1'hkR'(if'appllialile)feMOO ` k a ; i
❑Aquifer Storage and RecoverySalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
El
ft. ft.
❑Aquifer Test ❑Stormwater Drainage '
ft ft. i
❑Experimental Technology CI Subsidence Control �. ;,.„
• §DRICEINC<1~t a aiiaet'addttianalsheifillfnecessary) ' ,
❑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. 72 ft. OVER BURDEN
8-21-2023 72 ft• 365 ft• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: f .-�t. ft. w r.. f» +�4t
H&S Properties ft. ft. �- -
Facility/Owner Name Facility 1D#(if applicable) ft. ft. S E P 2 n 2023
225 Long Range Lane Lot 2 Leicester, NC 28748 ft. ft.
Physical Address,City,and Zip IT rs^' -r_ "`"'°`IVREMARllg pk x l== `ir ' W R3la-•a^rkk . .4�:...
Buncombe 961936213800000 "
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) C
�/jelm�
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W � 4}
8-28-2023
Signature of Certr Well Contractor Date
6.Ts(are)the well(s): OPermanent or ❑Temporary
By signing this forte,1 hereby certify'that,the well(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: • ❑Yes or IfiiNo copy of this record has beets provided to tlrc well ouncr.
If this is a repair.fill out known well construction information and explain the nature of the '
repair trader#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.came construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 365 (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 01 00'and 2O100) construction to the following:
10.Static water level below top of casing: 50 _ (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 Infection 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.c.auger,rotary,cable,direct push,etc.) I
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 Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: I
Also submit one copy of this form within 30 days of completion of
PILLS
13b.Disinfection type: Amount 35 well construction to the county health department of the county where
constructed.
Forac GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resoluces Revised August 2013
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