GW1--06028_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..WATER ZONES ._ ; . 7.,,i:
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft. i
NC Well Contractor Certification Number YS.OUTER CASING(for muttasetl iells)OR LINER Of ap licablee .
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 133 ft• 6 1/4 ' in' #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) '.
2021-00437 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): '.17.SCREEN', - > "
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
•❑Agricultural ❑MunicipallPublic ft. ft. in.1
ft. ft. in.❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(sin le)
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATEIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. ft
Non-Water Supply Well: 20 Bentonite Pumped
ft. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery '
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)- ° • ' •=' --- F, •,
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft. '
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING tOG(attach additional heets if necessary) -,,,` ; :
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soll/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 H. 133 ft. OVER BURDEN
08/23/2023 133 ft• 285 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft. _
5a.Well Location: ft. ft. N r--^�i„•,i.V A.-k-ptE'�.1L
Big Hills Const. LLC ft. ft. i F 2023
Facility/Owner Name Facility ID#(if applicable) ft. ft. S`P `t
Slate Dr, Candler, 28715 ft. ft. ,�,�f;.-5,1•w:.g ; ...
t r�
Physical Address,City,and Zip t
21.REMARKS°, 9•_ �' ,'.;.pW.i„a: •5,e a<. T;
Buncombe 86987907220000 this well was self certified.
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: Certification(if well field,one let/long is sufficient) 608/25/2023
N W
Signature ofCerncoacik22.
ell Contractor ! Date
6.Is(are)the well(s): 2Permanent or ❑Temporary ),signing fhereby Y)' (1 (were)B si nin this form,I cert that the well(s)was here 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 ElNo copy of this record has been provided to the well owner.
If this is a repair,fill but 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 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.sane construction,you can
submit one form. p SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 285 (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: 25 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,rise'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6. (in.)(in.) 24b.For Injection Wells ONLY: Inikaddition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ROTARY 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) 30 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 hcaltli department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013