GW1--07518_Well Construction - GW1_20231120

WELL CONSTRUCTION RECORD For Internal Ilse ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT COLLIN BANKS 14.%%ATER ZONES
FROM TO DESCRIPI ION
Well Contractor Name ft- ft.
4519-A ft• R. —
NC Well Contractor Certification Number 15 OUTER CASING(for multi-cased wells)OR LINER(if ap)11cahle)
FROM ICI I)LUIFTF:R I III(k\FYS NI All RIM
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 65 fi• 6 1/4 in. #21 Pvc
Company Name 16.INNER CASING OR TURING(geothermal closed-loopL
WEL2023-00104 FROM T(1 DI,,iETER 1 III(KMss 1212I,I
2.Well Construction Permit#: It. It. in.
List all applicable well permits(i.e.County.State,Variance.In/ection,etc.) It ft In.
3.Well Use(check well use): 17.SCREEN I --"
Water Supply Well: FROM TO DIAMETER SLOT SIZE _ THICKNESS MATERIAL
❑Agricultural OMunicipal/Public R. ft. in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) It.GROUT
FROM TO MA'I ERIAL EMPLACEMENT MEIHOD&AMOUNT
❑Irrigation 0 R• 20 ft• Bentonite Pumped
Non-Water Supply Well:
R. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable
FRO\ 7I) \AIEttl1t F\PI St F\1.\i\t11100
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stornwater Drainage — -
ft, ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCIttr!ION(color,hardness.snit/rock tape.grain sire.Oct.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft: 65 ft. OVER BURDEN
09/11/2023 65 ft• 245 ft• GRANITE
4.Date Well(s)Completed: Well ID# —
ft, ft.
5a.Well Location: ft. ft.
Haviture, LLC ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft ft
23 Haviture Way, Candler, 28715 ft. ft. NHV 2 0 ZDZ3
Physical Address,City,and Zip 21.REMARKS - '
Buncombe 9606690049
County Parcel Identification No.(PIN) , - .
5b.Latitude and I•ongitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat long is sufficient)
N w 09/29/2023
Signature of CerGo,,,,11-6GvvIl4Q,,,
ell ContractsDate
6.Is(are)the well(s): 2 Permanent or ❑Temporary
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 15,4 NCAC t/2C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONO copy of this record has been provided to the well owner.
Obis is a repair,fill out knots well construction information and explain the nature 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 same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:245 (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 sc 100') construction to the following:
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 20 ({{)
If water level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.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: 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
RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm)20 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-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013