GW1--06194_Well Construction - GW1_20230922

it
WELL CONSTRUCTION RECORD
For Internal Use ONLY: l'
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT COLLIN BANKS .
FROM TO DESCRIP,'LION
Well Contractor Name
ft. ft.
4519-A ft. ft. i;
NC Well Contractor Certification Number 15LOUTER'CA$I G:(for'muitt-cased=;Wills)ORLINEW(ifajlplicalde) '. .a ,.
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 66 it 6 1/4 in. #21 PVC
Company Name „16.ANNEW'CASING'OR TUBING'(W"e`n,1hertitsl'etosed loop '',,'.;; -«." ,.tH:. ` ,
WP-23-094 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): a ,
Water Supply Well: FROM TO DIAMETER _ SLOT SIZE THICKNESS MATERIAL,
❑Agricultural ❑Municipal/Public ft. ft. in.
ft. f.❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(s�in(single) in:,
❑Industrial/Commercial ❑Residential Water Supply(shared) �$'LYBOt)`f. ' "„ ,'^-'� °`"''°".,.: : -r'`
FROM TO 'MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft• 20 ft• Bentonite Pumped
Non-Water Supply Well:
ft. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: ft. ft. i,
❑Aquifer Recharge ❑Groundwater Remediation I9.,3AND/GRAYEGJPAGKK(1f appilkab(e).
C Aquifer Storage and Recovesy Salinity FROM TO MATEIHAL EMPLACEMENT METHOD
❑
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
_ ❑Experimental Technology ❑Subsidence Control
20 DRIELlN LOG(attach additional"shestsif necessary) .
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soilfrock type,grain size,etc.) '
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 66 ft• OVER BURDEN
08/14/2023 66 ft• 605 ft GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft. �la-- �'' '��G
James & Jenna Sorrels •
ft. ft. 4 'i �_.r\ E 3'
Facility/Owner Name Facility ID#(if applicable)
ft. It. SEP 2 2 Z023
Sugarloaf Rd., Brevard, 28712 ft. ft.
Physical Address,City,and Zip Nw,, , ti• itn', rt'�
21:.REMARK S*,:,' ,e 4tikcir r, ,1a jy
Transylvania 8585-71-7375-000
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 08/22/2023
Signature of Certt Well Contractor I . Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby certifi,that the well(s)was(were)constructed in accordance
with 15A 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 BNo copy of this record has been provided to the well owner.
If this is a repair,.fll 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 sante construction,you can
submit one form. SUBMITTAL INSTUCTIONS
I
9.Total well depth below land surface: 605 (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: 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 Center,Raleigh,NC 27699-1636
1/2 RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
Also submit one copy of this form within 30 days of completion of
PILLS
13b.Disinfection type: Amount 25 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