GW1--06016_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:�rn,ATER-zOlvi S . uw ,. ,",,,_
FROM TO DESCRIP I ION
Well Contractor Name ft. ft.
4519-A ft. ft. I
NC Well Contractor Certification Number ,-15.OUTER'CASING(for multi cased wells)ORL1NER(Waiflicable)3_.° -
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 85 ft• 6 1/4 I in #21 Pvc
Company Name 46.INNER CASING OR TUBING(geothermal closed-loopy':_ "
2023-207 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. 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.
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothernal(Heating/Cooling Supply) El Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18..OROUT.� t
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft' 20 IL Bentonite Pumped
Non-Water Supply Well: ft. H.
OMonitoring ❑Recovery Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL:PACK(if applicable). " , -
FROM _ TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20:DRiLLING LOG(attach additional sheets if necessary). -
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain site etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 85 it• OVER BURDEN
08/01/2023 85 ft. 305 ft. GRANITE
4.Date Well(s)Completed: Well ID# R. ft.
5a.Well Location: f�^^,. ,..r i , , 1
ft. ft. 4 t.k...�.1 ..f` �i
Alexander Properties ft. ft.Facility/Owner Name Facility ID#(if applicable) ft. ft. S E f_n
r v 2023
7 Ruff Rd, Leicester, 28748 ft. ft. t �ftC ,
fntv,it,r►.:^n t 9 Ur
Physical Address,City,and Zip .21.REMARKS _ . 4,1,,- ' ` WC4;'!f.t.S.'t
Buncombe 879182899900000 Well was self certified
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
6 '
(if well field,one lat/long is sufficient)
N W 08/03/2023
Signature of Ceru Well Contractor 1 Dale
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certi/i•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 ElNo 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 oldie
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 forte. SUBMITTAL INSTUCTIONS depth below land surface: 305 i
9.Total well
(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiiferent(example-3@200'and 2@100') construction to the following:
t� I
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: 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 Centi r,Raleigh,NC 27699-1636
RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 5 Method of test:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 2� well construction to the county health department of the county where
constructed.
Forst GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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