GW1--06007_Well Construction - GW1_20230920

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.W5`ATERRZO1 ES , > ;:
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft. I
NC Well Contractor Certification Number t 'Oliti edMIIstG.(for.;riiattt caseil:weltsj leLINE`tt:(if~•a'pptleabte): ... ....
FROM TO DIAMF.TF.R THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 805 ft. 5.25 : in' #188 Steel
16„INNER:CAStNG ORTIIBING(ttAtherniml:closed--iptrp) r. . ,
Company Name �--- --- -�-
2020-00435 FROM '1'0 DIAMETER 'THICKNESS MATERIAL2.Well Construction Permit#: ft ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. i"•
3.Well Use(check well use): 17<5CREEhI....::Ms....
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS . MATERIAL
❑Agricultural ❑Mtmicipal/Public ft. ft. iq•
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
ft. ft. in.
(H � g PP Y) PP Y( g
❑industrial/Commercial ❑Residential Water Supply(shared) I!{ GRQUT..t.:- - ..� o. ......` ....::: w.�z <.:•1
FROM TO MATF.RiAL FMPLACF.MFNT MF.TA01)&AMOUNT
❑h,igation 0 ft• 20 n• Bentonite Pumped
Non-Water Supply Well: -
❑Monitoring ❑Recovery ft. fL Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑Aquifer Recharge ❑GrouttdwaterRemediation 19 SAND/GRAVEL-P.ACKi(if applicable).. _:_.. _..�_ :....:
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology 0 Subsidence Control
.20 i 3RILLINGlifec attnef i ditienat sheets'if t4esitiO- --.- . iii•O;;...M:
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rocktype.grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑other(explain under#21 Remarks) 0 ft• 80 ft. OVER BURDEN
10/20/2022 80 ft. 805 n GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft. ,
5a.Well Location: ft. ft. ., -'i :� , 'R
Janna Ostapovich ft. n ,''-- -_' -t 4 1
Facility/Owner Name Facility ID#(if applicable) 29 2023
55 Heritage MTN PL., Fairview -- ft. ft. SEP
qf4 rt•a:F:n P _�4 g Ur.,
Physical Address,City,and Zip fat`lREI ARKS ..> MMO M,,.::. >. ..x..fr NCO .'r _.-: .:-:......
Buncombe 967730960300000
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
C 7/25/2023
Signature of Celt Well Contractor ; Date
6.Ts(are)the well(s): ❑�Permanent or ❑Temporary By signing this form,1 hereby eernj$'that the well(s)was(were)constructed in accordance
with 1 SA 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 ENo copy ofllris 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 r-emarla•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
S.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: 805 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi/ferent(example-3(aJ200'and 2(44100') 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 Infection Wells ONLY:1 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
(i.c.auger,rotary,cable,direct push,etc.)
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,4 Raleigh,NC 27699-1636
1/2 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
13b.Disinfection type: PILLS Amount: 27 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