GW1--06013_Well Construction - GW1_20230920

WELL CONSTRUCTION RECORD For Internal Use ONLY: I
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT COLLIN BANKS gxa ° - � ��•`� , ,. af
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number 15adtI atteMtING`(for mpliPiiii tP tfs ItigISIAI.{tninkilite) F
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. 140 rt• 6 1/4 #21 l PVC
Company Name .16 INNER iSStND.C1R'T;UB179G:{geathermatic1o5ed-t'40pj - •• 's'R
2023-00283 I.ROM 10 DIAMETER 'THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. 1 in.
List all applicable well permits(i.e.County,State,Variance,injection,etc.) ft ft. in.
3.Well Use(check well use): i'1 SCREIaN. : . 'VA''- ',�.
Water Supply Well: FROM TO , DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipallPublic ft. ft. , in.
['Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) Ili RUUT �'� s Cy s,� � a��
FROM TO . MATERIAL EMPLACEMENT METHOII&AMOUNT
['Irrigation 0 ft. 20 ft' Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ['Recoveryft. ft. Cap Top with Bentonite Chips
injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19SAND/GRitiV.ELPPr3CK`( .ajijil(ct'61e) 7, u . ''
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage --
ft. ft.
❑Experimental Technology ❑Subsidence Control <kitill uta itiGloat (Iacii addrhonatitiei itilecessi
❑Geothermal(Closed Loop) ['Tracer FROM TO , DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) 0 ft• 140 ft. OVER BURDEN
7-19-2023 140 ft. 405 ft. GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
95a.Well Location: ft. ft. " .�, i9 ^ )
Stacy Gossett ft. ft. i•"{— " ; qt� �"
Facility/Owner Name Facility ID#(if applicable) ft. ft. S E �l 20 L J
35 Overlook Drive Leicester, NC 28748 '
rt ft. r r f 4.J Ura
Physical Address,City,and Zip .'41 RENIAitKSt t; ' ') 3r 6ii$:
Buncombe 9701317472
County Parcel Identification No.(PIN) '
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one ladlong is sufficient) C
� I
N 7-24-2023
Signature of Celt Well Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby cerr j•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 or ENo 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 remarks section or on the hack 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: 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 ij'different(example-3(uj200'and 2(ar100) 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.c.auger,rotary,cable,direct push,etc.) j .
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cent r,Raleigh,NC 27699-1636
13a.Yield(gpm)
6 Method of test: RIG 24c.For Water Supply&Injection Wells:
i.
PILLS Also submit one copy of this form within 30 days of completion of
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