GW1-2023-02015_Well Construction - GW1_20230227

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
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GARRETT CLYDE BANKS :FROMRIPT�:.-::::.:s �a.x-:::..::::::��.:r".:•..:,.,
FROM TO DESCRIPTION
Well Contractor Name ft. ft. I, t
4519-A ft. ft.
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NC Well Contractor Certification Number FROM TO 1NG:fnriiiuDIAMF,TF.R TTRCKNFSS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 90 ft- 6 1/4 'in #21 1 PVC
Company Name rldtlNi+fBR?CtS[ 'ORT[11;13Yi e4flisFata4:St0et1[4 :==' raw :xg,:': .:1: 'z:-=;<`
WP 22-162 FROM DIAMK't•ER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable ucll permits(i.e.Coun),State,Yariance,Injection,etc.)
)check well use
ft. ft. in.
3.Well Use( .
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Water Supply Well: FROM TO DIANIETER SLOT SIZE I THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) ©Residential Water Supply(sin(single) ft. ft. in•
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❑IndustriaUCommercial ❑Residential Water Supply(shared) FROM TO MATERIAL I F•MPLACFMF.NT MF.TROD&AMOUNT
❑hTi ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. fr.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation F�9c�S',b3sJDfGi��I�A�t{�ifb-`"
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control .-.
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❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soilIrmit tvrie.grain size,etc.)
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 ft' 90 fr OVER BURDEN
01-12-2023 90 f° 165 fr GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location:
Victoria Breedlove Properties LLC ft. ft. } rYP tam VY'
Facility/Owner Name Facility 1D#(if applicable) ft. ft. t 7 20 •
219 Williams Way, Brevard ft. ft.
Physical Address,City,and Zip ::x:-.�-<:....:�•::�,.-;i::.r-::::.-_........-:
Transylvania
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8574-04-9391-000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification
(if well field,one lat/long is sufficient)
N W 01/13/2023
Signature of Cei-'Uftd Well Contractor j Date
6.is(are)the well(s): OPermanent or ❑Temporary
By signing this farm,l herehv certi/y that the wells)ww(lucre)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 ENo copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of thisJorm. 23.Site diagram or additional well.details:
You may use the back of this page to proxzde additional well site details or well
8.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: 165 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple%vells list all depths if di/fm•ent(example-3@200'aml 2(ar100D construction to the following: j
10.Static water level below top of casing 30 (ft.) Division of Water Resources,Information Processing Unit,
:
If wafer 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�e ter,Raleigh,NC 276994636
13a.Yield(gpm)
12 Method of test: RIG 24c.For Water Supply&Injection Wells:
,
Also submit one copy of this form'within 30 days of completion of
PILLS
13b.Disinfection type: Amount: 20 well construction to the county hleaith department of the county where
constructed.
Form GW I North Carolina Department of Environment and Natural Resources—Division of WaterRescurces Revised August 2013
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