GW1-2023-00658_Well Construction - GW1_20230105

• I
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS �5ATER' ONES.. . ... �..
f TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A
NC Well Contractor Certification Number
15-00T GA5fNG formutH cased:wetts OR-:11NEti fa` ficahte
FROM I TO I DIAMETER I THICKNESS I MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 105 ft- 6 1/4 �, in #21 1 PVC
Company Name td..11yI+IEtt.GAS1jYG4RTUBING 4othetma[closed-tao
2021-00466 FROaI DIAMNIER 'THICKNESS MATERIAL
2.Well Construction Permit#: R ft. I In
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft.❑Agricultural ❑Murticipal/Public in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single)
tt. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) FROM
l2AUT ate. t. F t`
TO MATERIAL -EMPLACEMENT WTHOD&AMOUNT
❑bri gation 0 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation „19:SANDiGRAYELYACl'.'d.a`"ca61e z
FRO51 TO MATERIAL EMPLACEMENT 51ETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
2OX.D91CIANC I Oa,a[taeli addttioit l'sheet4 if ecessary.i
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rmkri a Unin size,etc.)
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 ft• 105 ft. OVER BURDEN
10-18-2022 105 ft. 505 ft. GRANITE
4.Date Well(s)Completed: Well iD# ft. ft.
59.Well Location:
Bald Headed Builder ft. ft. =F° -N° NV'9-(
Facility/Owner Name Facility ID#(if applicable) ft. ft. JAN 0 V" •2023
31 Ted Linn Dr ft. ft.
Physical Address,City,and Zip 21:-12EMARKS,_,
Buncombe 969621552500000
County Pat-eel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certitication-
(if well field,one lat/long is sufficient)
N W 11 10-18-2022
Signature of Cettr Well Cuntractor Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this frnm,i hereby certify that the wells)was(were)constructed in accordance
with 15A NC.AC.02C..0100 or 15A NCAC 02C.0300 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofthis record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
repair under 921 remarks section or on the back ofthis 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 svelk ONLY with the same construction,you can
.submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface• 505 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iif'dfffie rent(example-3(eij200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resl urces,Information Processing Unit,
If muter level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY:I In addition to sending the form to the address in
ROTARY 24a above, also submit a copy of thus 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)
1.5 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this forml 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,
Form GW-I North Cmnlina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013