GW1--03519_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 F O'ATER7OrTES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number
15::OU'CERCASistG fo casedVelts O1bLINEt2'if's Lcable z
• FROM TO DiAMF,TF.A TRICKNF.SS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 75 n'riukt ft- 16114 i"• #21 PVC
1{c:INNER CA$IND OR I.UBING eiithet mai:slosed loo
Company Name
2023-0004/ FROM r0 DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: et rt '"•
List al(applicable well pennits(i.e.County,State,Parlance,Injection,etc.) ft. ft.
in.
3.Well Use(check well use): f7:SCAEEI!1 �.,.. . . _.:.� .
Water Supply Well: FROM TO I DIAMETER ISLOT SIZE THICKNESS NIATERIAt
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ©Residential Water Supply(single)
ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(Shared) ROUT TO MATERIAL EMPLACEMENT METHO
FROM D&AMOUNT
❑hTi ation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well: -
et. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: Ct. ft.
❑Aquifer Recharge []Groundwater Remediation
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
2tl`09JLGANC'16r ai aufi addtfiiiiialsheets:ifnocessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rmk tv a gmin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)J 0 f' 75 it OVER BURDEN
04-14-2023 75 it 205 it GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location:
Ronnie Caldwell ft. it. -• _ c �v 4�r
Facility/Owner Name Facility ID#(if applicable) ft, ft. MAY a
64 Smith Rd., Leicester
Physical Address,City,and Zip 21 a2EMARKS "� ' `fJ f :
Buncombe 9619362138
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 W 05/10/2023
dru
Signature of Ceit'llt1l Well Contractor Date
6.is(are)the well(s): RPermanent or ❑Temporary By sibming this•fieni,I herehv certify that the well(s)ivas(were)constructed in accordance
with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Con.Mruc•tion Standards and that a
7.Is this a repair to an existing well: ❑Yes or END copy ofihis record has been provided to the well owner.
If this is a repair,fill out knoitn well construction it formation and explain the nature of the
repair under#21 rennurks sectiun m•on the back ofihis form. 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 ivelle ONLY with the.came construction,),on cme
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 wells list all depths ij'dilferent(example-3@200'and 2(a-100') construction to the following:
10.Static water level below top of casing: 1 (ft-) Division of Water Resources,Information Processing Unit,
If 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
m 13a.Yield
(gP ) 7 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 Atnount: 25 well construction to the county health department of the county where
constructed. i
Forix GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013