GW1--03547_Well Construction - GW1_20230519

WELL CONSTRUCTION RECORD For hitemaI Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT COLLIN BANKS F�:�:si�l�fizcir
FRONT TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft.
ts:ou e>eAs rotam�ils ca�a,.�5ett orN1 R �t it� nt
NC Well Contractor Certification Number
FROM TO : DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rc. 154 ft.
6 1/4 n. #21 PVC
Company Name 16 11!7Nl R GAS(NGORT[}jai eo herma4'ctosedatoo ���a
055-2022-0663 FRONT TO DIAMETER 'THICKNESS NATERIAL
2.Well Construction Permit#: et. ft. in.
List all applicable urtll permits(i.e.County,State,Yariance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): st7 SCREEN ',
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) E IResidential Water Supply(single) ft. ff. in,
iRGROU I . alas
❑IndustriaUCotnmercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&.AMOUVT
❑IITi ation 0 et. 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery Cap Top with Bentonite Chips
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 9 5ANDIGIYz1'U,9VPAGK if.a lleable 414NMM ,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
it. ft.
[]Aquifer Test ❑Stotmwater Drainage
ft. ft.
❑Experimental Technology El Subsidence Control
'�2tt.�T3'1'I[L11Vs;i'lC1G Cattach`irdditiarial s"fleets`'if=iteeessury:sri�����w � '�z
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiVrock type. rain size,etc.)
❑Geothermal Heating/Cooling Return) ❑Other(explain under 921 Remarks) 0 ft 154 tt• OVER BURDEN
4-20-2023 154 ft- 405 ft. GRANITE
4.Date Well(s)Completed: Well ID# � �--.,„,
ft. ft. I_ q,z
So.Well Location: ft ft. 4 `` rt'• '�
Aggressive P&D LLC ft. fr. 1 -
1 .,. OZ3
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1923 Ridge Road Hendersonville, NC 28792
rt. rt.
Physical Address,City,and Zip ?-F1 1l;9WRRKS
Henderson 9690703180 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)
06
N `(, 05/15/2023
Signau7c_ofCert-ift4 Well Cuutractur Date
6.is(are)the well(s): 2Permanent or ❑Temporary By sisming this,form,I hereby cernfy�that the well(s)was(were)constructed in accordance
with 15A NCAC 03C.0100 nr 15A NCAC 02C.0200 H'ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy ofthis record has been provided to the well ouner.
If this is a repair.fill out Anouw tirll construction information and explain the nature of the
repair under 1121 remark,section or on the back oj'this farm. 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 if necessary.
For multiple injection or non-water supply wells ONLY with the same 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 ij'dilf rent(example-3 00'and 2(a100) construction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
Ij',Awer 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) 3 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.
Forst GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013