GW1--06033_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 v:14.WATER ZONES , �. ,
FROM TO DESCRIPTION _
Well Contractor Name ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number .15.OUTERCASING(for multi-cased w lh)OR LINER(if Applicable) ,
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 115 ft• 6 1/4 'i"• #21 Pvc
Company Namc 16.INNER=CASIN;G,OR TUBING(geothermal closed Loop)" ' -.
2023-00069 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. 'in.
List all applicable well permits 0.e.County,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN .. c •
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ID Water Supply tt. ft. in.
PPY) PPY
❑Industrial/Commercial ❑Residential Water Supply(shared) "IS GROITC v.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft• 20 ft• Bentonite Pumped
Non-Water Supply Well:
ft. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation :19.SAND/GRAVELPACK(if applioable)'=
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG tattach additional sleets if necessary) �.
❑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• 115 it. OVER BURDEN
08/30/2023 Well ID# 115 ft• 405 ft• GRANITE
4.Date Well(s)Completed: ft. ft.
5a.Well Location: ft. ft. P" "'� r' "'6 i ";
4.....Christopher Paul Schembri ft. ft. t: ,,, " '-',��r ..: r.m=
Facility/Owner Name Facility 1D#(if applicable) ft. ft. SE P r 9 2023
216 Thistle Ridge Ct, Fairview 28730 ft. ft.
Physical Address,City,and Zip
21`RcAnrcS ln;�.y, �R' .:•z3 _` r
Buncombe 967551894300000
r.�yf�41 iL'L�
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 09/01/2023
4-13
Signature ofCerti Well Contractor Date
6.Is(are)the well(s): OPermanent or OTemporary By signing this Jbrm,I hereby certi/j•that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 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 owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or o,t 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.supple wells ONLY with the.same construction,you can
submit one form. 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 if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:25 (ft.) Division of Water Resources;Information Processing Unit,
If water letel 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
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ROTARY 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
13a.Yield m 5 Method of test: RIG 24c.For Water Supply&Injection Wells:
(SP ) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 20 well construction to the county health department of the county where
constructed. I
i
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013