GW1--06030_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 . .-.r 1E", ;.
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft. '
NC Well Contractor Certification Number IS.OUTER'CASING(for multi-eased wells).OR LINER(if applicable)
CLYDE SAWYERS &SON WELL & PUMP INC +1 FROM ft.. 38 TO DI/4 AMETER! THICKNESS MATERIAL PVC
6 din. #21 � PVC
Company Name 16.;INNERCASING OTh TUBING(geothermal closed-loop)
-00156 FROM TO DIAMETER' THICKNESS MATERIAL
2023
2.Well Construction Permit#: 6 ft. ft. 'in.
List all applicable well permits(i.e.Coup,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 ❑Municipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) El Residential Water Supply(single ft. ft. in.
;GRO Tt
❑industrial/Commercial ❑Residential Water Supply(shared) F18R. ;.,
FROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft• 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft. Cap Top with Bentonite Chips
OMonitoring ❑Recovery
Injection Well: ft. ft.
12 Aquifer Recharge ❑Groundwater Remediation -.19.SAND/GRAVEL PACK(if applicable).'.' - ,* --4
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑StormwaterDrainage 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 size,etc.)
❑Geothermal(Heating/Cooling Return) ID Other(explain under#21 Remarks) 0 ft. 38 ft. : OVER BURDEN
07/25/2023 38 ft. 485 ft. GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
Sa.Well Location:
Pamela D. Revis ft. ft. ..;', f -,,�:q''1 Fir r'N,.
ft. ft. t Z t‘,.. „d a e.r: V IL—Ls:
Facility/Owner Name Facility ID#(if applicable) ft. ft.
0 Turkey Creek Rd, Leicester, 28748 SEP 2, 9 2023
ft. ft.
Physical Address,City,and Zip 21.REMARKS . " < -If y Ae.'^A�r ^rs3"3,2/if*
Buncombe 8792857449 Div SOG
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 09/11/2023
Signature ofCer_sctoti Well Contractor Dale
6.Is(are)the well(s): l7Permanent or ❑Temporary By signing this form,1 hereby certif}•that the wells)was(were)constructed in accordance
with ISA NCAC 02C.0100 or l5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo 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#21 remarks section or on the back of this forts. 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. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:485 (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@l00') construction to the following:
10.Static water level below top of casing: 35 (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
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 Center,Raleigh,NC 27699-1636
RIG 24c.For Water Simply&Injection Wells:13a.Yield(gpm) 5 Method of test:
Also submit one copy of this form within 30 days of completion of
PILLS
13b.Disinfection type: Amount: 20 well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013