GW1--03513_Well Construction - GW1_20230519

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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 TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A
NC Well Contractor Certification Number 15.OU rERxG�15( r fo'r`mulf3rea�e8=t+'elPs OR Lf1�ER ifs"a I[catiie ��
FROM TO I DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 60 ft- 16 1/4 #21 PVC
Company Name
X1'01Nf4ER CAS(,fY 0WTI uBIMI eofherme[
2022-00242 FROM '10 DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:
ft. (t. in.
List all applicable urll permits(i.e.County,State,Variance,Injection,etc.)
([. ft. in.
3.Well Use(check well use): 11SGREEdY a <a�' %r� _.:
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) ©Residential Water Supply(sin(single) it ft. in.
:111GRA
UUTs S,,`❑lndustrial/Commercial ❑Residential Water Supply(shared) TO MATERTAL ENIPLACEMF.NT METHOD&AMOUNT
❑bTi ation ft' 20ft• Bentonite Pumped
Non-Water Supply Well: Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well:❑Aquifer Recharge ❑GroundwaterRemediation YP>AXxAit.aw�liatiW��<.�r:��� ���„`,.
❑Aquifer Stooge and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. tt.
❑Experimental Technology ❑Subsidence Control
20TS12I»ClT C►G tattacti`additiatal'she€sit riecessary n'r ''".
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soilfrocktype.grain size,etc.)
❑Geothermal Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 60 ft. OVER BURDEN
5-16-2023 60 rt• 385 ft• GRANITE
4.Date Well(s)Completed: Well ID# _ yr
5a.Well Location:
TLF Woodlands LLC ft. (t. Mff
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft. vPrli"0.'.'�l Pr:^.v«lsT4Y>3 l:('.:i
2214 Sand Branch Road Black Mountain, NC 28711 ft. ft.
Physical Address,City,and Zip �21:t€E1'IARKS�11
Buncombe 062619729100000 Well was Self Cetified
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one IaUloug is sufficient) KA
N Wn AA 05/18/2023
Signature ofcc, Well Contractor Dale
6.Is(are)the well(s): 2Permanent or ❑Temporary By sigming this fin•m,1 herehy certify that the well(s)Ivas(Ivere)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy ofthis record has been provided to the well miner.
If this is a repair,fill out knouvn well construction information cord explain tite mare of the
repair under#21 remarla•section or on the back ofthic 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: 1 construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. p C SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 385 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ij'di/fn-eni(example-3 dl 00'and 2(W100') construction to the following:
10.Static water level below top of casing: 50 (ft.) Division of Water Resources,Information Processing Unit,
If ureter 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 forth within 30 days ofcompletion of
13b.Disinfection type: Amount: 35 well construction to the county health department of the county where
constructed. ; I
Form GW-1 North Carolina Department of Euvironmeut and Natural Resources—Division of Water Resources Revised August 2013