GW1-2023-01951_Well Construction - GW1_20230227

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
: ``.�', 1:�ZOM8
GARRETT CLYDE BANKS aF
FRO5I TO DESCRTPTION
Well Contractor Name ft. ft. i
4519-A ft.
NC Well Contractor Certification Number �^fieOUfiPR L/CSINGr atuld=ciisi xYct(sIt317�1Ff2'iP a
FROM TO DIAMETER TMCKNF.SS NrATF.R1AL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 56 ft. 6 1/4 I I"• #21 PVC
Company Name
�714tV [2;CASftYG>OReCl7$11Zs eOt7ieiiiiifclased=l:`'
2021-00340 FROM ro DIAmF.rb:R 'THICKNESS MATERIAL
2,Well Construction Permit#:
ft. it. , in.
List all applicable well permits(i.e.County,Slate,Variance,Injection,etc.) ft. ft. in
3.Well Use(check well use): "„i'7.3SGRErA!Rm,;,:
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS AIATERr.4L
ft.
❑Agricultural ❑Municipal/Public ft. in.
❑Geothermal(Heating/Cooling Coolin Supply) EIResidential Water Supply(single) ft. ft. in.
(H � g PP Y) PP Y g
❑IndustriallCommercial ❑Residential Water Supply(shared) F1R GRQUT FROM TO MATF.RiAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft. 20 ft, Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge ❑GroundwaterRemediation 19 SANDIGE#A''TfTPACIC`if:`a Ilcsi`1@ "' xr;; s'�# �
FRO5I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology El Subsidence Control
�2tlI1WGIaNGx;C+'}G:aFtaeh:iraiiltlil�beefsrtitecessary�, `"` ` " �
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiUrock tv a grain sire,etc.
❑Geothermal (Heating/Cooling Return ❑0ther(explain under#21 Remarks) 0 ft, 56 ft. OVER BURDEN
11-16-2022 56 fa 245 ft. GRANITE
4.Date Well(s)Completed: Well ID# " �..,.,
5a.Well Location: ft. ft. '� ..�4 .fi 9y qQ. .,.
Jansen Trent Gossett ft. irFEB. 9 7
7071
Facility/Owner Name Facility ID#(ifapplicable)
18 Grizzly Drive Leicester, NC 28748 et. rt. env+n< �� I s�rX 74,
91 S
Physical Address,City,and Zipit
Buncombe 9701674506 �
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22. 6Certification:
(if well field,one lat/long is sufficient)
N W 2-10-2023
Signature of Certi Well Cuutractor Date
6.is(are)the well(s): l7Permanent or ❑Temporary By signing this form,I herehr certify'that the well(s)was(were)constructed in accordance
ivith 15.4 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 E]No copy of this record has been provided to the well ouncr.
If this is a repair,fill out knoun well construction inrormation and explain the natrire of tine
repair under 921 remark-section or on the back ofthis jarm. 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 ivells ONLY with the.fame construction,you can
submit one form. A 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 ij'di fl rent(ecample-3 dr 00'and 2(ru100) construction to the following:
10.Static water level below top of casing:40 (ft) Division of Water Resources,Information Processing Unit,
Ij water level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection 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
1 !
13a.Yield(gpm) Method of test: RIG
10 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
PILLS
13b.Disinfection type: Amount• 25 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 Resuurces Revised August 2013