GW1--03585_Well Construction - GW1_20230522

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT COLLIN BANKS 414?R'AGEIZz0ft5� r _ �
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number 16N)uTEIt=GASI W1,fm mUltl ea'�¢'d.ti'eIIi P0 It,LINitWill' Iteabl'e"M,:%W*V,
FROM TO DIAMETER THICKNESS MATF.RTAT.
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 32 ft. 6 1/4 #21 PVC
Company Name L u16,IN ER GAS N.(S t)RTI}B3NG euthermatrelpsed,0013
FROM
2784r�7 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): 17:5(REEN ,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) EResidential Water Supply(single)
❑lndustrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT NTF"THOD&.ANfOUNT
❑in; ation 0 et. 20 ft- Bentonite Pumped
Non-Water Supply Well:
rt. rt. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediatiolt 19`:$ANl)/tilCdI'AIfita"'lli1Q° �.�•..'--
❑Aquifer Storage and Recovery ❑Salinity Barrier
FROM
ft. TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
"�tl�TSi�ILT � 'G-attaeh�nddi�unasheets'ift ceasat v�::... f :.. ab.'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soilf o k type, rain size,etc.)
❑Geothermal Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 rr• 32 ft OVER BURDEN
6-22-2022 32 rr• 265 tr• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
Sa.Well Location:
Keith Griffin ft. ft. MAY 2 2 2023
Facility/Owner Name Facility ID#(if applicable)
159 Spothorse Lane Mars Hill, NC 28743
Physical Address,City,and ZipZ1xkN1ARKS ' ; & � �3s• �
Madison 9727-61-1882
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 lat/long is sufficient)
N Wn AA 7-5-2022
Signature of Cettt Well Coutractur Date
6.Ts(are)the well(s): 2Permanent or ❑Temporary By signing this ftn•nr,I he•ehv certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy of this record has been provided to the well owner.
If this is a repair,fill out knoisn well construction information and explain the nature of the
repair under 921 remarla•section or on the back ofthis 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 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: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ij'dilferew(example-3(200'and 2(a.100) construction to the following:
10.Static water level below top of casing: 20 (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 Infection 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 C.en;ter,Raleigh,NC 27699-1636
i
13a.Yield(gpm) 50 Method of test- RIG 24c.For Water Supply sr Injection Wells:
PILLS Also submit one copy of this foriri'within 30 days of completion of
13L.Disinfection type: ATnount: 25 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