GW1--04550_Well Construction - GW1_20230713

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT COLLIN BANKS .Ala: '-;,40tV0• . vnWi. `. 05,
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft.
•KletAiTEIV ASIfi0(foritiitd iiia tiN ORI;INER{ifrlt Ileslil4, - ,.2
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 83 ft• 6 1/4 #21 Pvc
Company Name 1d:1NIVERCASII WDTt=*TU.BING(t<e4ilt¢rmatclosed-tgolt)> 1 '' ' "`
2023-00024 FROP1 !HAMKI'KR THICKNESS MAT'ERIAI.
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): ;141.JSCRCCNW 2 MA %'..., 'AW ;
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
:Agricultural ❑Municipal/Public
ft. ft.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
in.
❑Industrial/Commercial ❑Residential Water Supply(shared) =18 GRUU3142 ,? 5 x � � �a :
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑h'rigation 0 ft• 20 ft• Bentonite Pumped
Non-Water Supply Well:
ft. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater RemediationI9:3SANDIGRAY.Et;I'ACKK( :arp11c1ilile) =" h ,ttiMAreadM
FROM TO MATERIAL _ EMPLACEMENT METHOD
:Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology El Subsidence Control
zf120+D121CIA 1G106. ttaelil ddiiiatitaheetr)f'aiiisa> :— s.<4.6,VAt
❑Geothermal(Closed Loop) ['Tracer FROM TO DESCRIPTION(color,hardness.soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 83 ft• OVER BURDEN
5-18-2023 83 ft. 325 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft. ^:''••3, il .T.,
Corey Johnathon Meyers ft. ft. • y..,. 1< 4-...
Facility/Owner Name Facility ID#(if applicable) ft. ft.
527 Shumont Road Black Mtn, NC 28711 ft. ft.
Physical Address,City,and Zip 21l REMARKS' ..:?' t< ' .,- ry' r31.>t i'?,fia ;$
Buncombe • 062492942700000 c,N
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one IaUlong is sufficient) C
/f
LLL///////�)))
N W tLC 6-6-2023
Signature ofCerh Well Contractor Date
6.is(are)the well(s): ❑O Pe)manent or ❑Temporary By signing this firm,1 herehy certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes nr ONo copy of this 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 1121 renrar/n•section or on the back of this form. 23.Site diagram or additional well details:
You may use the hack 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 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: 325 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 dr 00'and 24100) construction to the following:
10.Static water level below top of casing: 40 (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 Injection 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,
l FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 8 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
PILLS
13b.Disinfection type: Amount 30 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