GW1--03611_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 FROM TO DESCRTPTION
Well Contractor Name ft. ft.
4519-A
NC Well Contractor Certification Number
15 (9ll fEli;CtCSl11G folEi=cased"Its`•ARA'INE [tc$lite` a
FROAf TO DTAMF.TF.R THTCKNF.SS prATF.ATAI.
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 76 ft. 6 1/4 i"• #21 PVC
__
Company Name �WJNNEfi�ING QWFI-1l�,G edthermaf;clased-rob
WP22-150 FROM '1'0 DIAMETER 'THICKNESS MATERIAL
2.Well Construction Permit#: ft it. in
List all applicable scl1 permits(i.e.Cotany,State,Variance,Jnjccrion,etc.) ft. ft. in,
3.Well Use(check well use): t5RRR
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
[]Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) tt. ft. in.
N � �n
❑IndustriaU 19GRUUT
Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑iiri ation 0 ft' 20 ft- Bentonite Pumped
Non-Water Supply Well:
Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediationBSAND/G1IAUEL1'i1CKf" licat)1'er � t�
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO hL1TERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control F
�0 bRILL1NC'1 C1G, attach:additiau:l streets fnetess v`.
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness•soil/rock tv a rain size,eie.l
❑Geothermal(Heating/Cooling Return ❑Other(explain under#21 Remarks 0 ft' 76 ff• OVER BURDEN
1-17-2023 76 ft. 205 ff• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
Y�_u
So.Well Location: ft. ft. -_ ° % _
Don Rogers ft. ft. MAY2 2 2023
Facility/Owner Name Facility ID#(if applicable)
45 Gristmill Drive Brevard, NC 28712
Physical Address,City,and Zip 21 RE 6TARhS)i � ��' d k�
Transylvania 8585-19-0640-000 Well Was Self Certified
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well Geld,one ladlong is sufficient)
N `l, 05/11/2023
Signature of Ccit-ifk4 Well Coutractur Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this fin-ni,1 herehv certify that the well(s)"•us(were)constructed in acemdance
With 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 N ell Construction Standards and that a
7.Is this a repair to an existing well: [--]Yes or ©No copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remark-section or on the back oj'this_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: 1 construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-crater supply wells ONLY with the satne constriction,you can
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 a17 depths lf'di••lferent(example-3 di 00'and 2(a-100') construction to the following:
10.Static water level below top of casing: 25 Division of Water Resources,Information Processing Unit,
(ft)
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 withhr 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) V Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form 1within 30 days of completion of
136.Disinfection type: Amount 20 well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013