GW1--07520_Well Construction - GW1_20231120

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
i
1.Well Contractor Information:
GARRETT COLLIN BANKS 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519—A ft. ft.
NC Well Contractor Certification Number 15.OU f ER CASING(for multi-eased Wells)OR LINER Of algt.icab k)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 69 ft- 61/4 #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2023-00354 FROM '10 DIA,IFIER ,HICK NESS NIAlI'HIA1.
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 DIANIF IFR SLOT SIZE THtCKNI-S5 SI%TF RI M.
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) E(Residential Water Supply(single) 11• ft. n.
❑lndustrial/Commercial ❑Residential Water Supply(shared) ?K GROUT
FROM TO NI ATFRIAL FM PI S(FAIFNT METRO')&AMOLNl
❑irrigation 0 ft, 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring DRecovery ft. ft. Cap Top with Bentonite Chips
injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediution 19.SAND/GRAVEL PACK(if applicable)
FROM TO MAIERIAI. EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier II. ft.
❑Aquifer Test ❑Stormwater Drainage •
ft. ft.
❑Experimental Technology ❑Subsidence Control
—
20.DRILLING LOG(attach additional,sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color.hardness,soiVrock type.grain size.etc.l
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 69 ft. OVER BURDEN
9-8-2023 69 ft. 185 ft. GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
Robert MACKEY ft. ft. —
Facility/Owner Name Facility ID#(if applicable)
It. ft.
277 BROOKS COVE ROAD CANDLER, NC 28715 ft. R. —� , '
Physical Address,City,and Zip 21.REMARKS
Buncombe 9608168660
Claim,, I'.0 cel identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification: 6
(if well field,one lat/long is sufficient)
N 9-20-2023
Signature ofCats Well Contractor Date
6.is(are)the well(s): ®Permanent or ❑Temporary By signing this/arm,1 hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction uction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo 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 farm. 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 with the.came construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 185 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths t)different(example-3 al 00'and 24100') 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 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.) 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 r� Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount 20 well construction to the county health department of the county where
constructed.
F„rtn t,\l-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013