GW1-2023-02764_Well Construction - GW1_20230417

WELL CONSTRUCTION RECORD For hntemal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT COLLIN BANKS F14LWATL11-Zfiil
FRO51 TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A
NC Well Contractor Certification Number
tS:OItTERGASItYG:fai mti/p.ca"sert�vel(s:OW-XINER if.a"11,66te` � ?
FROM TO DIAMETER ! THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 70 ft. 6 114 ' h• #21 PVC
Company Name 16.rI YtY12tGA [1VC�QR 7lIBING'" liermatctosed=lo �s
2020-00031 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable ur(l permits(i.e.Caunty,State,Variance,Injection,etc.) ft. ft. in
3.Well Use(check well use): tT52?12EEN � � �a " ;r
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. nn
❑Geothermal (Heating/Cooling Supply) gResidential Water Supply(sin(single)
❑IndustriaUCommercial ❑Residential Water Supply(shared) V''18:&R(0 ,U1'"'. y :� • x °. ` ..
FROM TO MATERIAL EMPLACF.MF.NT MF.THOi)&AMOUNT
❑1r,; ation p ft' 20 ft- Bentonite Pumped
Non-Water Supply Well:
Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19 SANA/G 1�I'ACKx a "Iieable 4 t MM"'Wo
FROM TO MATERIAL EMPLACEMENT 5IETHOD
❑Aquifer Storage and Recovery []Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stotmwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20 DRINt160G.attacti.)±dditiuiial'sheets)f necessai•Y `"' .����'"
❑Geothermal(Closed Loop) ❑Tracer FRODI TO DESCRIPTION color,hardness,soil/rock t„e ram sae,etc.)
❑Geothermal Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rr' 70 ir• OVER BURDEN
rr• fr•
4.Date Well 4-3-2023 s)Completed: Well 70 245 GRANITE 1D# ft. ft.
5a.Well Location:
Joseph Edwards
ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) APR
y 2023
ft. ft.
Sutton Farm Road Asheville, NC 28806
Physical Address,City,and Zip
Buncombe 9618363231
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 ��, 4-13-2023
Signature of Certl Well Contractor VqAL/ Date
6.is(are)the well(s): gPermanent or ❑Temporary By signing this firm),l herefir certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 11'ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No copy of this record has been provided to the well o)tner.
If this is a repair,fill out knuuvr well construction b fm•mation and explain the nature of the
repair under#21 remark section or on the back of this_Jorm. 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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same constructimt,you can
submit one form. 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'difjerent(example-i d 00'and 2(a100� construction to the following:
10.Static water level below top of casing•40 (ft.) Division of Water Resources,Information Processing Unit,
If water 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 27699-1636
13a.Yield(gpm) 10 Method of test- RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount; 25 well construction to the county health'department of the county where
constructed.
Fore)GW-1 North Carolina Department of Euvironment and Natural Resources—Division of Water Resources Revised August 2013