GW1--06029_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: ATERZONES .--- °- ,47 P-.. t r �.
FROM TO DESCRIPTION'
Well Contractor Name ft. ft. I '
4519-A ft. ft.
NC Well Contractor Certification Number "15.'OUTER CASING(formula-eased vk9lis)'OR LINER tlf applicable)'
FROM TO DIAMETER THICKNESS
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 131 ft' 6 1/4rn• #2 MATERIAL#21 PVC
1 A
Company Name -1t6 INNER CASINO OR TUBING'(g t lternial elosed-loopyfif,, _
2021-00350 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. j in.
3.Well Use(check well use):
17:"BCREEN ,>': _ _z_ ",:".,11
Water Supply Well: FROM TO DIAMETER 'SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
0 Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 ORDll1 r i� 2ri� x° i m�
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft• 20 ft• Bentonite Pumped
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation ,'19:SAND/GRAVEL PACK(if applicable w, , ,.,''''<
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
0 Experimental Technology ❑Subsidence Control
`10..DR1LL1NGI':'()G(attach addttioda4she&ts if necessary .;:!: ,A,, ',`M
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soWrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2]Remarks) 0 ft• 131 ft• I ' OVER BURDEN
08/24/2023 131 ft• 225 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
Big Hills Const. LLC ft. ft. ^_.. x� i? f; 7-'4� A
Facility/Owner Name Facility ID#(if applicable) ft. ft.
l"' "'��"Z , '�
Slate Dr., Candler, 28715 ft. ft. SEP 2 9 2023
Physical Address,City,and Zip
Buncombe 86987917210000 21:RFMAR1C�rt ��, , ,
County Parcel Identification No.(PIN) 1 t I u
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lot/long is sufficient)
k6
N Wern 08/25/2023
Signature of CWell Contractor • Dale
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form,1 hereby certiih'that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC 0,2C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or IE1No copy of this record has been provided to the;we//owner.
If this is a repair,fill out 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: 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 form. I SUBMITTAL INSTUCTIONS 1
9.Total well depth below land surface: 225 (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: ln!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 Center,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 25 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
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