GW1-2023-02857_Well Construction - GW1_20230418

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT COLLIN BANKS F4:�t5�
FROM TO DESCRD'TTIPTI ON
Well Contractor Name ft. ft-
4519-A ft.
NC Well Contractor Certification Number 1S 0 [ETT« 111(tr fo'i multi eas :tuells.ORy!TJVE .if.=a" tica`fc
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 et. 91 ft. 6 114 i"• #21 PVC
Company Name 7T6;IN#VER:CM NG:ORTt3B1NG'eo"ihervia['ciosed=too a
055-2023-0110 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable wr:ll permits(i.e.County,State,Variance,Injection,etc.) in.
3.Well Use(check well use): ;I7.SCRt�EN :' 01' _
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) E'IResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lni ation 0 et• 20 ft- Bentonite Pumped
Non-Water supply well: rt. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: t't. ft.
.-_.
❑Aquifer Recharge ❑CroundwaterRemediation I?�S'A�i1IG1 �1'At�K."ii'�ali �b 4_11x:.' ft .��a""-
FROl11 TO MATERML EDIPLACEMENT DIETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control ,f
lu20.1�UYI;IL�L`1NG1,Ct tairach additfUnBT-sheett;if�'iecessary.. �' ;�� - ���
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness sorVrock type. rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 91 ft. OVER BURDEN
3-20-2023 91 R• 705 tr• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft .-•.. .�-. _ ,-,_•�,
5a.Well Location: rt. rt. :_z.r 'K,';e�t
David Tollefsen ft. fr.
Facility/Owner Name Facility ID#(if applicable) fr -
ft. ft.
679 Summer Orchard Drive Hendersonville, NC 28792 rt. rt. ;-i.. .,;.� Ur';!
t .
Physical Address,City,and Zip
Henderson 0601886959 Well Was Self Certified
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 `1 3-22-2023
Sign t Ir
are of cdwell ContractorWVLL/ Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this ftn-ni,I hereby certify that the well(s)was(were)constructed in acenrelance
ivith 15A NCAC 02C.0100 or 1 SA NCAC 03C.0200 Nell 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.
If this is a repair,fill out known well construction it furmation and explain the nature of the
repair under#21 remarks-section or on the back oJ'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
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY mith the,came construction,you cute
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 705 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths fj'different(erample-3 dr 00'and 2(w.100') construction to the following:
10.Static water level below top of casing: 160 (ft.) Division of Water Resources,Information Processing Unit,
IJ'w ater 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 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this forms within 30 days ofcompletion of
13b.Disinfection type: Amount: 35 well construction to the county hea�thl department of the county where
constructed.
Form GW-1 North Carolina Department of Euviroament and Natural Resources—Division of Water Resources Revised August 2013