GW1-2021-06479_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Garrett Banks 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519A ft. ft.
NC Well Contractor Certification Number .15.OUTER CASING for multi-cased wells OR.LINER.if a licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 42 ft. 6.25 in. #21 PVC
Companv Name 16.INNER CASING OR TUBING(geothermal closed-loop)'
FROM
2.Well Construction Permit#: 2021-00016 ft TO ft DIAMETER THICKNESS MATERIAL
in.
Lied all applicable well perwas(i.e.County Slate,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.
❑Geothermal(Heating/Cooling Supply) EIResidential Water SuPPIY(single) f. f. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 "' 20 ft- Bentonite Pumped
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa licable -`
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. %
❑Aquifer Test ❑Stormwater Drainage
rt. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness soilimck type,grain sin,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rf 42 ft. OVER BURDEN
8-4-2021 42 rf 725 ft- GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
MODCABINS LLC ft. ft. r 1
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
575 LAUREL VALLEY DRIVE ASHEVILLE, NC 28805 I
ft. ft. rrrta4'�on Prose
Physical Address,City,and Zip 21.REMARKS
Buncombe 9770-61-9333
County Parcel Identification No.(PIN)
5E.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field one NtAong is sufficient)
N W &Mett nw 9-16-2021
Siguature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary y j. y (J (were)B signing this nrnn, I hereby cerd that the ire/!s war here 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 FINo copy oj7his record has been provided to the well owner.
if Ihis is a repair,/ill out known well construction inJormalion and explain the nature of the
repair tinder 21 remarks section or on the hack o/dus jbrm. 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.
Vox multiple injection or non-waler.supply we/A ONLY with the same construction,you can
mbnul one lbrnn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 725 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
I-or multiple wells list all depths ifdifPrent(example-3 n 200'and 2 n 100') construction to the following:
10.Static water level below top of casing: 200 (ft.) Division of Water Resources,Information Processing Unit,
//waler level is above ca.sine,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b. For Iniection Wells ONLY: Iniaddition 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.anger,votary,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.field(gpm) 1/2 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 35 well construction to the county health department of the county where
constructed.
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Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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