GW1-2023-02771_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 O T DESCRiPTTOT
FROM TO
DESCRIPTION
Well Contractor Name ft. ft. I ll
451.9-A
r
NC Well Contractor Certification Number FROM EkICASING for molh.cased yetis.I TIUlVEK; s llcaATE ..
FROM TO DiAMRTF.R THICKNESS 31ATF.RiAi.
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 1130 ft' 6 1/4 in #21 PVC
Company Name KANNER CMING OR:C1161N0 'eothermnE closed 1po
2021-00439 FROM .1'0 DIAMETER THICKNESS 31ATE:R141
2.Well Construction Permit#: ft. ft in.
List all applicable well pennits 6.e.County,State,Yariance,Injection,etc.) ft. ft.
in.
3.Well Use(check well use): ,.17.SCREEN:_.:: ...
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS 3IATERiAL
ft. ft. in.
❑Agricultural ❑Municipal/Publie
❑Geothermal (Heating/Cooling Supply) EIResidential Water Supply(sin(single) It. ft. 1n•
❑Indmtrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATF.RI L EMPLACEMENT METHOD&AMOU.NT
1111Ti ation 0 ft. 20 n• Bentonite Pumped
Non-Water Supply Well:
ft. ft. Cap Top with Bentonite Chips
❑Monitoring []Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 1'I,SAiYD/GFIAVEL.PAGK:d:a'' 'ible s `... :
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery El Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
::2d=1)12tI;LTI�C:Y'QG,allaeli:addt arialsheels�ieeessary=:. �.:..... ...s�:.: ....:;
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiVtvck type. rain size.etc.)
❑Geothermal (Heating/Cooling Return ❑Other(explain under 921 Remarks) 0 ft• 130 ft• OVER BURDEN
4.Date Well(s)Completed: 03-09-2023`,I,ell ID# 130 ft• 205 n GRANITE
p ft. ft.
5a.Well Location:
Big Hills Construction ft. ft. � - 1.,M
fl
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Slate Dr., Lot 33 -
Physical Address,City,and Zip
MARK$
Buncombe 86986987640000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:(if well field,one laUlong is sufficient)
N W 03/10/2023
Sig<ta[tu-of CetU Well Contractor Dale
6.is(are)the w•ell(s): 2Permanent or ❑Temporary By signing this farm,1 hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 sA NCAC 02C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: [1Yes or E]No copy of this 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 921 remark-section or on the back ofihis.lorm. 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 o•non-water supply wells ONLY with the svnre construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface• 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wellr'lisr all depths ifdiljerent(erample-3(d200'and 2(a1001 construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If tit vier level is above casing.use'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Inlection 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) 12 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 25 well construction to the county health department of the county where
constructed.
Forth GW-1 North Catalina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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