GW1--06011_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 lai mufclgsc �� �
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519—A ft. ft. 1
NC Well Contractor Certification Number
1MOt1TERMASIICI (fo titiliti-cased ilts)tittiLINkii(if ppltcab e fi x,
FROM TO DIAMETER , THICKNESS h(ATF.ALAi,
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 53 ft• 6 1/4 1 in• #21 Pvc
Company Name 1 C6WBRT SI1 Griffin)ilhiG;<(i*ep`iftermatcTased?tptijt) ' �'' sir.
2017-00473 FROST TO DIAMETER THICKNESS MATERIAL2.Well Construction Permit#: ft. ft. j in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): il:5Z?R B;CI" I '''' F itY.A " .., ' 4 '
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipallPublic ft. - ft. in. ,
❑Geothermal(Heating/Cooling Supply) ®Residential WaterSupply(single) ft. ft. in.
❑IndustriallCommercial ❑Residential Water Supply(shared)
FROM TO MATF.RiAL EMPLACEMENT NiF,THOiI&AMOUNT
❑irrigation 0 ft' 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft. Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 649 /ORAVEI PAGICEilapplieat leW ° . '
FROM TO MATERIAL EMPLACEMENT METHOD
❑❑Aquifer Storage and Recovery Salinity Barrier 1 .
ft. ft.
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control
liAI{IGCIfi1 it(attaeL`addItlairulails'if feces (I
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type.groin size.etc.)
❑Geothermal(Heating/Cooling Return) ❑other(explain under#21 Remarks) 0 ft. 53 ft. OVER BURDEN
7-14-2023 53 ft. 325 ft. GRANITE
4.Date Well(s)Completed: Well ID# ft ft
5a.Well Location: ft. ft. r 't P 7
Mari Hinst ���'`" � �s �`' ��
ft. ft.
Facility/OtvnerName Facility ID#(if applicable) ft. ft. SEP 2 2023
55 Lemon Creek Drive Candler, NC 28715 •
ft. ft. r . .3 l;r.:�
Physical Address,City,and Zip llttv.tt*'�<'. (� - N
Buncombe 8686943563 zt l:>r ARKS � ;.< .r �
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) COrtrtd4:64
N W7-24-2023
Signature of CeWell Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary
By sibming this form,1 hereby certify that the i+•ell(s)was(were)tonstru<7ed 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 or ©No 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#21 remarks•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 dt 00'and 24100) construction to the following:
10.Static water level below top of casing: 20 (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: Inladdition 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.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centf r,,Raleigh,NC 27699-1636
RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 50 Method of test:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 35 well construction to the county healtli department of the county where
constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013