GW1--06018_Well Construction - GW1_20230920

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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.-�1ATERZQNES �.�t.. . ..:
FROM TO DE,SCRu'rlbN
Well Contractor Name ft. ft. 1
4519-A ft. ft.
NC Well Contractor Certification Number .IS.OUTER CASING(formnitt•c.aseoI*hllsTO.KLiNER(if App_ cable)'�' ,,
FROM TO DIAMETER! THICKNESS MATERIAL 4
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 50 ft• 6 1/4 j'in• #21 Pvc ,I
Company Name �i16 INNERCASING'OR-TUBING.(geoihermal'closed loop) :r'-
2023-00038 FROM TO DIAMETER THICKNESS MATERIAL • •
2.Well Construction Permit#: 8 ft. ft. in.
List all applicable well permits(i.e.County,State,Variance.Injection,etc.)
ft. ft. ;in. i
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAI.
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) B. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 1S.''GROUT „, ', - - �.;; ,r,,,-:
FROM TO MATERIAL EMPLACEMENT METHOD 8 AMOUNT
❑Irrigation 0 ft• 20 ft• Bentonite Pumped I.
Non-Water Supply Well: ft. B.
❑Monitoring ❑Recovery Cap Top with Bentonite Chips
Injection Well: ft. ft.
Aquifer Recharge ❑Groundwater Remediation .19 S;AND/GRAVEI;`PACK(if applicablc)'' 1
❑ . ,
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft. 1;
0 Experimental Technology ❑Subsidence Control !
;20.DRILLING I,OG'(attach addittonal<shei is if necessary) t . .; '
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soli/rock type,Crain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 50 ft. OVER BURDEN
4.Date Well(s)Completed: 07/21/2023Well ID# 50 ft• 265 ft• GRANITE
ft. ft. ne^^t"�
ipi. ` 1I,
5a.Well Location:
ft. ft.
-�.� ..!'Lam.t
John Treadway ft. ft. SEP 24�3
Facility/Owner Name Facility lD#(if applicable) ft. ft. CU
Nora's Way, Leicester, 28748
ft ft. r ^
Physical Address,City,and Zip
^ t( r i. it
,21,REMARKS r'',, . :t ., �'..w 1
Buncombe 8783717353
County Parcel identification No.(PIN) ;I
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5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:well field,one!at/long is sufficient)
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N w 08/01/2023
Signature ofCern Well Contractor Dale
6.Is(are)the well(s): 2 Permanent or ❑Temporary By signing this arm,I hereby ecru 'that lie well(s)was were constructed in accordance
s s f ) > (. (were)
with 1SA NCAC 02C.0100 or 15A NCAC 0 C.0200 Well Construction Standards anethat a
7.Is this a repair to an existing well: ❑Yes or IEINo 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#2/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 o iIwell
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 sane construction,tau can
subrnitone form. SUBMITTAL INSTUCTIONS I
9.Total well depth below land surface: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion oflwell
For multiple wells list all depths ifdif)erent(example-3@200'and 21/l00') construction to the following: I'
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10.Static water level below top of casing: 20 (ft.) Division of Water Resources,
es,Information Processing Unit, 'II
If water level is above easing,use'•+'• 1617 Mail Service Center,Raleigh,NC 27699-1617 1
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11.Borehole diameter: 6.25 (in.) 24b.For Iniection 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
15 RIG 24c.For Water Supply&Injection Wells: 41
13a.Yield(gpm) Method of test:
PILLS Also submit one copy of this form Within 30 days of completion of
13b.Disinfection type: Amount: 20 well construction to the county hcaltli department of the county where
constructed.
Form GW-1 North Carolina Depanmenl of Environment and Natural Resources—Division of Water Rcsoprces Revised August 2013
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