GW1--06005_Well Construction - GW1_20230920

1
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT COLLIN BANKS 14. tii titer ' ° ; � °
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number
OtER'OAS1 4foli lltl a 4 tie`1tiltite 1 N1yR4 a0traliii) "
FROM _ TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft, 92 ft• 6 1/4 ; in• #21 Pvc
Company Name ,ti AN1~l t $ti Ul cT;Uf 1Nfs''(I;e ttibt'aaa e 144 '.._< � a
2022-00449 FROM !HAMMER I'l'ER 'THICKNESS DIAN:RIAI
2.Well Construction Permit#: It. ft. in.
List all applicable well permits(i.e.County,State,Variance,injection,etc.)
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER: SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lri ation 0 ft• 20 H• Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft. ! Cap Top with Bentonite Chips
Injection Well: ft. ft. 1
❑Aquifer Recharge ❑Groundwater Remediation 40741;iSV/ L Pliel({lt„atit i,e : ' C•4,
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
F Sr :ir R 1;
#Zti�`i}kI1''����G Cattaeti•addltian4t'sheets�il;mcessii° ' `� -
❑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• 92 ft• i OVER BURDEN
7-18-2023 92 ft• 405 ft• I GRANITE
4.Date Well(s)Completed: Well ID# '
ft. ft. ,
5a.Well Location: ft. ft. .,
Oleg Pishchanskyi ft. ft. F- —��'s< .t,
Facility/Owner Name Facility ID#(if applicable)
ft. ft. SEP 2 2023
56 Lawson Ridge Rd Leicester, NC 28748 ft. ft.
Physical Address,City,and Zip K , , x
Buncombe 97016360530000 f ARK ti f3t �DI f � t
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 7-20-2023
Signature ofCertt Well Contractor jh:o Date
6.is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,1 herehr certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 nr 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No copy of this record has been provided to the well ossner•.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of 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 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 if different(example-3 dl 00'and 2(a.;100') construction to the following:
10.Static water level below top of casing: 30 (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,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
6 RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
Also submit one copy of this form within 30 days of completion of
PILLS
13b.Disinfection type: Amount: 35 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
i