GW1--06039_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: t ,
GARRETT COLLIN BANKS XPEWATOMONES,: � WW ,.' —,,WKNOSId
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number 15:pIiillt Gii.S 0 (for t4nIH easettliifs}OR 4IM12(fin licatile)
FROM TO DIAMETER THICKNESS MATERIAI.
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 46 ft• 61/4 j in. #21 Pvc
Company Name L6='1NNER`iGA$INC 61t::TUBUiG.(I;eo'thermat-c iiic`d=loop " , —.W
2023-00126 PROM '1'O DIAMFUER 'THICKNESS atA'I'N.RIAI.
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): 1'7 S?Rglr, 7 ION'
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in..
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply ft. ft. in.
� f� g PP Y) PP Y(single)
❑IndustriaUCommercial :Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hrigation 0 ft. 20 ft• Bentonite Pumped
Non-Water Supply Well: ft. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: ft. fL i
19 SANDIGi A,VELTAt✓tcAiraiitllic tiUMW 7TIFLACEMENT❑Aquifer Recharge ❑Groundwater RemediationFROM TO MATERIAL METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier '
ft. ft. .
❑Aquifer Test • ❑Stormwater Drainage .
ft. ft.
❑Experimental Technology El Subsidence Control
flU-A IL, 'OT(SG tiiiicli'raddifik iF%heetililiecesituvII INK' .—
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size.etc.)
❑Geothermal(Heating/Cooling Retu n) ❑Other(explain under#21 Remarks) 0 ft. 46 ft• OVER BURDEN
9-8-2023 46 ft• 165 ft• j GRANITE
4.Date Well(s)Completed: Well LD# ft. ft.
5a.Well Location: ft. ft. L .� •v r a so,i
Jensen Pertiller ft. ft. I,,,.., V, f~-1.,.
Facility/Owner Name Facility ID#(if applicable) R. ft. S E P 9, n 2023
109 Hookers Gap Road Candler, NC 28715 ft. ft.
Physical Address,City,and Zip ; 21 REMARKS .w a �.fix• It
Buncombe 86986339140000 u� tl'��•
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification
(if well field,one lat/long is sufficient)
N W 9-8-2023
Signature ofCertl Well Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 1SA NCAC 02C.0/00 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or IDNo copy of this record has been provided to the well(tiler.
If this is a repair,fill out known well constructkm information and explain the nature of the
repair under#21 remarks section or on the back of;his firm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY wills the same construction,you can
submit one form. cG SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 1 65 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 ar 00'and 2(d lll0') construction to the following: l
l
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
111.Borehole diameter: 6.25 (in.) 24b.For Infection 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.) I '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: RIG 24c.For Water Supply&Injection Wells:
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