GW1--06038_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 14I "`A' `z—NE8 ;: :A~ ,` 0 WW `CI,
FROM TO . DESCRIPTION
Well Contractor Name ft. ft. I '
4519-A ft. ft. 1
NC Well Contractor Certification Number 15::OU'l ER GASIN G(for'riiiiitf cased'wv etls)AR:I:iNEI ()i"aii i licaile)i K s:�,, `> >I
FROM TO DIAMETER THICKNESS MATERIAL.
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 74 ft. 6 1/4 i in. #21 PVC
Company Name g16,`lNNER Ci1SIKG',OICT,I'1,8111C�(ReotbeKmalc]died=tpop)' -
2023-00375 FROM DIAMETER THICKNESS IsIATF:RIAI.
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): 1<7•IS(RE1;Np ..n AK41, 50Lx `'?° ,W , `:4
Water Supply Well: FROM TO DIAMETER , SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑MunicipallPublic ft. ft. , in.'
R. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
❑lndustrial/Commercial ❑Residential Water Supply(shared) 1R:zGR()1)T �e". c � � uk,
FROM TO 111ATERIAL EMPLACEMENT METHOD)&AMOUNT
❑irrigation 0 ft' 20 ft' Bentonite Pumped
Non-Water Supply Well:
OMonitoring ❑Recovery ft. ft. Cap Top with Bentonite Chips
injection Well: ft. It.
❑Aquifer Recharge Groundwater Remediation 41J:SANlti/Glit4ti?E'I.sPA`CsI il:fijipl[ t"I161/Z4VZOWM s w z`eltev —
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery El Salinity Barrier
ft. ft.
DAquifer Test El Stormwater Drainage
ft. ft.
❑Experimental Technology El Subsidence Control 20 RILEIN ;EO,G.ta f el aild fionaril eets%faiecasiiirvj ;
❑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- 74 ft• OVER BURDEN
9-5-2023 74 ft. 365 ft• GRANITE
4.Date Well(s)Completed: Well TD#
ft. ft.
5a.Well Location: ft. ft.
Reagan Riddle ft. ft. ` - *I--i iI�s- F
Facility/Owner Name Facility ID#(if applicable) ft. ft. S E P 2 9 2023
7 Lois Glen Lane Candler, NC 28715 ft. ft.
Physical Address,City,and Zip /2t REtiTARIMV ..' ;4.= ..� `n iris 0�'.,:
Buncombe 86952961100000 Well Was Self Certifie
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 WC ti 9-12-2023
6
Signature of Celt) Well Contractor Date
6.Ts(are)the well(s): OPermanent or DTemporary By signing this form,I 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 ©No copy of this record has been provided to the well owner.
If this is a repair.fill out known well construction information mid explain the nature of the
repair under#2I remarks section or on the back ofthis firm. 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)ton-water supply)yells ONLY with the same 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-i tit 00'and 2(aj100') 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:
(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) 1 00 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount 35 well construction to the county health department of the county where
— constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013