GW1-2023-02762_Well Construction - GW1_20230417

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT COLLIN BANKS FROM.�A1DR TO DESCRH'TT sE.RIPT"--- . . �.. �.. .�..
FON
Well Contractor Name ft. ft.
4519-A
NC Well Contractor Certification Number 15•.OUT.�RlCAS1tG for maltl cased welts UkStINEtt ifa"licabk
FROM TO DIAMFTF.R THICKNFSS NIATF.Rr TAT,
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. 53 ft. 6 1/4 421 PVC
.>I1Yl+VEt21C':StNly OR'`fUBl1VCY 'kothel�iiaEctosetl l0ti
Company Name ':
2022-00395 FROM 10 DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: fr. fr. in.
List all applicable well pennies(i.e.Coun(y,State,Yariance,Injection,etc.)
Ct. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM I TO DIAMETER I SLOT SIZE I THICKNESS MATERIAL
fr. ft.❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Coolin Supply) ElResidential Water Supply(sin(single) ft. ft. in.
❑lndustriaKommercial ❑Residential Water Supply(shared) 7R:`GROUT.. . ,.... .. j......, t
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Fri ation 0 ft' 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 24:SAlYD/ORA LFAGK rf.a bee.::... :::
FRONT TO MATE L EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier RIA
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
;2t1?fRiC G�1:OG":attach addltiiipia sfreelfs.ifnecessa ::: --------: ..::.. .,.;
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness•soil/rock ri e rain size.etc.)
❑Geothermal (Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 53 ft. OVER BURDEN
03-16-2023 53 ft• 325 ft. GRANITE
4.Date Well(s)Completed: Well ID# .T.,,
5a.Well Location: fr. ft. E x' ..•. i °a" ,� �.._,F'
Angelica Santiago ft. fr. APR 1
Facility/Owner Name Facility ID#(if applicable)
ft, ft.
68 Holly Ridge, Candler
Physical Address,City,and Zip
Buncombe 86960521020000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
(ifwell field,one fat/long is sufficient)
N `l 04/06/2023
SL-2-CrU Y.ignature of Cntt Well Contractor Date
6.is(are)the well(s): OPermanent or ❑Tempora.ry By signing this,iorm,I herehr cert?fy�that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nuture of fete
repair under#ll 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 multiple injection or non-water supply wells ONLY with the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface• 325 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2(ty100D construction to the following:
10.Static water level below top of casing:40 M) Division of Water Resources,Information Processing Unit,
If baler 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 Center,Raleigh,NC 276994636
13a.Yield(gpm) 30 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
PILLS well construction to the county health of the county where
136.Disinfection type: Amount: 25 i
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013