GW1-2022-07618_Well Construction - GW1_20220817

WELL CONSTRUCTION RECORD For IntemaI Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS
1:4 ytTER701 „ . .v , _,.. x'
FRONI TO DESCRIPTION�
Well Contractor Name
ft. ft.
4519-A
NC Well Contractor Certification Number 41KI611T,gAVI",IN foi 5fiultl ctise e115 . MUNK jP ti" Ijc>ib)e �,
FROM TO DIAMETER I THICKNESS MATF.RLAI,
CLYDE SAWYERS & SON WELL & PUMP INC +1 It. 81 ft. 6 1/8 '" 1 #21 PVC
Company Name „1 NIIER G 51:Mt Q)3JN0'"euiberm&F:'clbsed;lo'o"'
2021-00627 FROM •1'0 DIAMETER 'THICKNESS NIATER1.A1.
2.Well Construction Permit#: rt. ft. in.
List all applicable well permits(i.e.County,Slate,Ya iance,Injection,etc.) (t ft in.
3.Well Use(check well use): z
Water Supply Well: FROM TO DIAMETER SLOTSI7E THICKNESS . MATERIAL
❑Agricultural ❑Mtmicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) fl. tt. ini
❑IndustriaUCommercial ❑Residential Water SuPPIY(shared) u1R GR�t7T � a ter " 77
.=ti ..
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Ellmgation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation59--Siqvkr1?AGK;
❑ FROM TO MATERIAL EMPLACEMENT METHODAquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stomtwater Drainage
ft ft.
❑Experimental Technology ❑Subsidence Control 9
41 0-`.'.(I 'atffac'ti A11d1t19R�1t 51 t a9 n i:; `�v.Jx✓ x,r.
❑Geothermal(Closed Loop) ❑Tracer FRONI TO DESCRIPTION color,hardness,soiVrock tv a gr.in size,etc.)
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 rL 81 ft OVER BURDEN
f° ft
4.Date Well(s)Completed: 06-17-22 Well ID# 81 305 GRANITEft. ft.
5a.Well Location: It. fL
MICHAEL GURTO e. In
ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. I r t�
63 ROSIES STARLIGHT TRAIL ft. ft. 2072
Physical Address,City,and Zip ZI;eREi41ARK$' i1 i1T ?
BUNCOMBE 97031040460000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one IaUlong is sufficient) -nArvA
N W 06-28-2022
SigniatFe-ofCcrtillef Well Contractor I Date
6.Is(are)the well(s): RIPermanent or ❑Temporary y, S � (
B si min b thin f• form.I herehv ecru -lh6t the wall s)was hvere constructed in accordance
with I SA NCAC 02C.0100 or I SA NCAC 02C.0200 11'ell 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.
If this is a repair,fill out known Hell construction information and explain the nature of the
repair under 021 remarks section or on the back t f 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
S.Number of wells constructed: 1 construction details. You may also attach additional pages ifnecessary.
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: 305 (ft,) 24a. For All Wells: Submit this iform within 30 days of completion of well
For multiple wells list all depUzr ijdiJJirenl(example-d(a�00'and 2(w100) construction to the following:
10.Static water level below top of casing: 30 (ft. Division of Water Resources,Information Processing Unit,
If i4 ter level is above casing.use"+" ) 1617 Mail Service Center,Raleigh,NC 27699-1617
1
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY: iIn 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
m 13a.Yield
(gP ) Method of test:
7 RIG 24c.For Water Supply&InjectionlWells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 1 9 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013