GW1--03511_Well Construction - GW1_20230519

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�A TO DESCRIP�� ,N,�1RM
'2 d, I. �r�ll�� ��
TION
Well Contractor Name
i
4519-A ft.
NC Well Contractor Certification Number CIS OU4l Rt ASiIYG fdraituitl ea`sedClis Jul ilbte5�
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft, 112 ft- 6 1/4 in. #21 PVC
Company Name 76'IiVNERC591t G;t)ii.T;i)B1111Gr egthermntclosed-bo'% R TW
2022-0047o FROM DIAMETER 'THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable ux;11 permits(i.e.County,State,Variance,Injection,etc.) ft. tt in
3.Well Use(check well use): ;ft7 SCREEN
Water Supply Well: FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Coolie Supply) ®Residential Water Supply(single) ft• ft' in
� gj g PP Y) PP Y g
❑Industrial/Commercial ❑Residential Water Supply(shored)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑in; ation 0 fc. 20 ft- Bentonite Pumped
Non-Water Supply Well:
«. rt. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
injection Well: 1't. fL
[]Aquifer Recharge ❑Groundwater Remediation .19 SANV/GP-A" El,PACW,ifa" lici 616%" . - : .'r .n•
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
2U DR1I CilL9s 1 t1C latiacii addltf(ifi sheet"s'•ifimcessa%v
[]Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiUrmit type. rain size,etc.)
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 ft• 112 ft• OVER BURDEN
3-23-2023 112 rt• 305 ft GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location:
Jennifer Blue De Leeuw
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
MAY
Case Cove Road Candler, NC 28715
ft. ft.
Physical Address,City,and Zip
;RENIARKS:"'+.'£�" ���"s"�,� �" �
Buncombe 9606862941 This 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 Iattlong is sufficient) 6
N W n AA 4-25-2023
Sign tune ofCeiti Wtfic .raocWr Date
6.is(are)the well(s): 21Permanent or ❑Temporary By signing this farm,I herebv cerrrfy�that the well(s)was(were)constructed in aceordimee
With 15A NCAC 0IC.0100 or 15.4 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 owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remark,section or on the back ofthis 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 ifnecessary.
For multiple injection or non-water supply wells ONLY with the sage construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface• 305 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple%Tells list all depths ij'different(erample-3 dl 00'and 2(a,100) construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
Ij'waler 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
20 of test: RIG 24c.For Water Supply&Injection W
13a.Yield(gpm) Method ells:
Also submit one copy of this for mwithin 30 days of completion of
PILLS 30 well construction to the county health department of the county where
13b.Disinfection type: Amount
constructed.
i
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013