GW1-2023-02016_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:
GARRETT CLYDE BANKS FROM ERZONE3 ION
FROM TO DESCRIPTION
Well Contractor Name ft.
i
4519-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased'wells)OR LINER(if a"Hcable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 44 ft- 6 1/4 11 ' #21 1 PVC
Company Name 16.INNER CASING OR TUBING eotherinal closed-loo w ' -
WP22-135 FROM TO DIAMETER ' THICKNESS K MATERIAL
2.Well Construction Permit#: ft. ft. J' in.
List till applicable well permits(i.e.Counq,,State,Variance,Ityection,etc.) in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. ft. in. 11
❑Agricultural ❑Municipal/Public
[]Geothermal(Heating/Cooling Supply) El Residential Water Supply(single)
ft. ft. in.1
.GROUT ,� • °. :;L�,..r _• � < ':,".... ,- ,- ,.
El ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft. 20 ft- Bentoni'te Pumped
Non-Water Supply Well:
ft. ft. �
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable• ;` <
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonmwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional-sheets if neeess'a
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiltrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 44 ft. OVER BURDEN
1-9-2022 44 rc• 805 rr• I' GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location:
Alan Siegel
Facility/Owner Name Facility ID#(if applicable) ft ft. •� / 21+n23
1371 Walnut Ridge Road Brevard, NC 28712 ft. ft. ; Ir1,c.„
Physical Address,City,and Zip 21.'REMARKS i tix '•�="::."`. " r''
Transylvania 8594-71-4023-000 Well was Celf certified
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
01/10/2023
N W
Signature of Certt Well Contractor Dale
6.Is(are)the well(s): ❑e Permanent or ❑Temporary By signing this forrn,I herebv certifythat the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAG 02C.0100 Well 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.
11Ihi.v is a repair,fill out known well construction it formation and explain the nature of the
repair under#21 remarks section or on the back of 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
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For nodtiple injection or non-water supply wells ONLY with the sante construction,you can i
.suhnrir one./ornr. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 805 (ft.) 24a. For All Wells: Submit this Iform within 30 days of completion of well
Fo•multiple wells list all depths t(di(jerent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 150 (ft) Division of Water Resources,Information Processing Unit,
I/lvater level is above casing,use"+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- 6.25 (in.) 24b.For Iniection 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 Ccat1 r,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 Method of test: RIG 24c.For Water Supply&In,jectionfWells:4
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 35 well construction to the county heflth department of the county where
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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