GW1--07526_Well Construction - GW1_20231120

WELL CONSTRUCTION RECORD For Internal Use t)NLY
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT COLLIN BANKS 14,WATER ZONES
FROM 10 DESCRIPTION
Well Contractor Name ft. ft,
4519-A fl. ft.
E '' ,, .• cased wens)OR 41NER(if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATER1.41.
CLYDE SAWYERS & SON WELL & PUMP INC +1 n 21 ft• 6 1/4 in. #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2022-00549 FROM 10 IIIAMN:I'ER IIIICKNE:SS NIA IIRIM.
2.Well Construction Permit#: ft. ft. in.
List all applicable we//permits(i.e.County,State,Variance,Injection,etc.) ft• ft. in.
3.Well Use(check well use): '`i7:S'.RFEN <° ' :/ "xW:V,:
Water Supply Well: FROM TO DIAMETER St01SI/I IHICKNESS MCIIRI%I.
ft. ft. in.
❑Agricultural ❑Municipal/Public
fL ft. in.
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(sin le)❑Industrial/Commercial ❑Residential Water Supply(shared) it.GROUT
IRO1I TO NI:ITFRIAI. IMP!A(-F MIN 1'Si ETHOI)S.1\10CNT
❑Irrigation 0 ft' 20 ft' Bentonite Pumped
Non-Water Supply Well:
❑Monicoring ❑Recovery ft. ft. Cap Top with Bentonite Chips
injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EX PLACENIENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology 0 Subsidence Control
U.DRILLING,LQG(attach additional sheets if necessary) .
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size,elc.t
❑Geothetmal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 21 ft. OVER BURDEN
9-20-2023 21 ft• 605 ft. GRANITE
4.Date Well(s)Completed: Well ID# ft. R.
50.Well Location: ft. ft.
Jason Brock ft. R '�
Facility/Owner Name Facility ID#(if applicable) ft. ft. '`v r .rr J
1179 Dillingham Road Bernardsville, NC ft.
Physical Address,City,and Zip
—
21.REMARKS _
Buncombe 979404787500000 WELL WAS SELF CERTIFIED
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one ladlong is sufficient)
N VI,' 10-11-2023
Signature of Cott Well Contractor Date
6.Ts(are)the well(s): OPermanent or ❑Temporary By signing this form,i hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 nr I SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E1No 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 hack of this jOrm. 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: 605 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijfdifferent(example-3(a3200'and 2(4100) construction to the following:
10.Static water level below top of casing: NA (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
13a.Yield(gpm)0 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
tab.Disinfection type: Amount: 30 well construction to the county health department of the county where
constructed.
F,:i ro t,\\-': North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013