GW1--06014_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 14i.WATER,ZONES, .,, r_ ° '4,v,., , . ° . .
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number ,:I5:OUTER CASING(for multi eased=s'sells)`ORLINER(if ap Ifeable)' '
FROM TO DIAMETER. THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 59 ft• 6 1/4 i"• #21 Pvc
Company Namc 16.INNER CASING OR TUBING(geothermal dosed-loop);' °,> ,
2023-00206FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(7.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
❑Agricultural ❑Municipal/Public ft. ft. in.
OGeothermal(Heating/Coolingu l ElResidentialWaterSu 1 (single) ft. tt. in.
Supply) Supply
❑Industrial/Commercial ❑Residential Water Supply(shared) '18.GROUT ��,.:2
; "
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
El Irrigation 0 ft• 20 ft• Bentonite Pumped
Non-Water Supply Well: ft. ft
OMonitoring ❑Recovery Cap Top with Bentonite Chips
Injection Well: • ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVELPACi((if applicable)-
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
•
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology OSubsidence Control '
20.-DRILLINGLOG(attach addHionatslieets if necessary):`. °'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness sof Urock type,grain size etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft, 59 ft. OVER BURDEN
08/01/2023 59 ft• 125 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft. ',l FY
Alexander Properties ft. ft. -6taa„ .0'1 t.
Facility/Owner Name Facility ID#(if applicable) ft. ft. SF P d n ZUZ3
9 Ruff Rd, Leicester 28748
ft ft.
Physical Address,City,and Zip 5 x 5'r "�''��t�f
Buncombe 87918592940000 z1.1KARx��t= . �r >>�nL, .uv,,, �y
t'�
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one IatAong is sufficient)
k:6
N NV 08/07/2023
Signature of Cent Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby cm•ti&that(he well(s)was(were)constructed in accordance
with 1SA 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 ONo copy of this record has been provided to the well owner.
If this is a repair,full out knotmu 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 saute construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 125 (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@200'and 2@100') 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: 111,1 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.) j
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ' 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: RIG 24c.For WaterSupply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 20 well construction to the county health department of the county where
constructed.
Ferns GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013