GW1--03514_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:
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GARRETT COLLIN BANKS 14R
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A
NC Well Contractor Certification Number S.tS..OfS GER:C`A511Y ,fot4mNti cast d ii e0s.01tt MER if u" IiEelite .,.
FROM TO DIAMETER THICKNESS MATF.RTAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ec. 115 ft• 6 1/4 in. #21 PVC
Company Name
16:lNVE1iGASf1YOR,T.lIB1N(: �eoitietviute3vsed ttia" s �
2023-00139 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft ft in
3.Well Use(check well use): A11ACaR9rN 1ra%_WWN W�
Water Supply Well: FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
ft. ft.❑Agricultural ❑Municipal/Public in.
❑Geothermal (Heating/Cooling Supply) OResidential Water Supply(sin(single) ft. ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared)
FROM TO MATF.RTAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery rt. ft. Cap Top with Bentonite Chips
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation1?SA?3DIGC1ilV ,PAFHif
❑Aquifer Storage and Recovery El Salinity Barrier FROM TO AMTERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
x2U'1tf211y1:INti<T:t�t:4aftaeli�addfhunai'�shee4s i£iieeess>iry..�'�����n.::
❑Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTION color,hardness,so!Vmck type,gmin size,etc.)
❑Geothermal (Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 115 ft OVER BURDEN
4-14-2023 115 ft- 405 ft. GRANITE
4.Date Well(s)Completed: Well ID# ft. ft. 3 k._ ,rj
Sa.Well Location: ft. ft. ice.6. ' • 1--` ,,
Seth Solesbee ft. ft,
Facility/Owner Name Facility ID#(ifapplicable) —ft MAY' I Q
. ft.
518 Pole Creasman Road Asheville, NC 28806 ft. ft. In r��,= �ter:zi-,w!>j Ura
Physical Address,City,and Zip
Ys Y, P 7Z.1 -IIENI'IRKSe . ' � f `�&T.V kV`-`°` '. x4 W"W"1 04
Buncombe 96264165140000 This well was self certified
County Parcel ldenlification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if we0 field,one lat/long is sufficient)
N �� (715 4-20-2023
Signature of CerU Well Ccntractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in acenrdanre
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 41 ell Construction Standards mid that a
7.Is this a repair to an e)dsting well: ❑Yes or E]No copy ofthis record has been provided to the well owner.
If this is a repair•fill out known weft construction information and explain the nature of the
repair[order#21 remarb,section or on the back gj'lhis 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 saute construction,you can
.submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iif'diJferew(example-3 di 00'ant[ (w 2100') construction to the following:
10.Static water level below top of casing: V 0 (ft.) Division of Water Resources,Information Processing Unit,
IJ'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.)
DiAsion of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method of test: RIG 24c.For Water Supply sr Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 35 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013