GW1--06697_Well Construction - GW1_20241108

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
• i4:naTlrR=zoivr s
GARRETT COLLIN BANKS I
FROM TO DESCRIPTION
Well Contractor Name ft. ' ft.
•
4519-A • It. . ft. i ' .
NC Well Contractor Certification Number 15:OUTER CASINIG(for.multi caseitiivells)'OR!LIN CE(if,'ap plicable)> .
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FROM 'TO DIAMETER THICKNESS MATERIAL.
CLYDE SAWYERS &SON WELL & PUMP INC +1 ft• 81 fl't;i 6 1/4 ; in. #21 _ PVC
Company Name 6 INNER CASING Ox 1T`SINFs(geotherniaCclosed lei p)'=
WEL2024-00532 "ROM To DIAMETER THICKNESS MATERIAL`
2.Well Construction Permit#: ft. ft. in.
List all applicable wr//permits(i.e.County,State;Variance,Injection,etc.) rt. ft.
in.
3.Well Use(check well use): A4 SCRECN '.< ...
Water Supply Well: FROM TO DIAMETER _SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ' ❑Municipal/Public ,
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in.
(H c� g PP Y) PPY a
❑lndustrial/Commercial ❑Residential Water Supply(shared)
lti>GROUT... .
FROM TO MATERIAL F.MPLACF.MF.NT METHOD&AMOUNT
❑laigation • 0 ft• 20 ft• Bentonite Pumped
Non-Water Supply Well:
ft. ft. ' Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEI PACK:(ifappliiable) : . . :` _ •
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft - -
❑Aquifer Test ❑Storntwater Drainage -
ft. ft.
❑Experimental Technology ❑Subsidence Control ii.20,1DRiLL1NG.OG.(attaeh addit(analsfiee......ecessar4)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(colnr,hardness,soil/rock type.grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 - ft• 81 ft• 'OVER BURDEN
81 . ft• 405 ft• 7GftAN1,TEE
4.Date Well(s)Completed: Well ID# ft. ft. .,.;a.�..: :t.x=: ,,�' ..-...Li
5a.Well Location: ft, ft.
GarrettNOV Q $ %(i�4
Banks
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. iri:.,"A•L•`' ' ' �r'ti:^i;J %1
60 Cathy Rd., Candler `: s'^i)
ft. ft. ,
Physical Address,City,and Zip 21 REM ARK5
Buncombe 869850607200000
If certified
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 I 10-21-2023
- • Signature of Cedt Well Contractor Date
6.is(are)the well(s): l7IPermanent or ❑Temporary By signing this.form.1 hereby coif 'that,the well(s)was(were)constructed in accordance
with 1SA NCAC 02C.0100 nr 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes nr No • copy of this record has been presided to the well ensues.
If this is a repair,fill out known well construction information and explain the nature of the
repair corder 1121 remarks section or on the back of'this farm. 23.Site diagram or additional well details:
You may use ate.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 '
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9.Total well depth below land surface: 405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiljerent(example-3(aj200'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.c.auger,rotary,cable,direct push,etc.) 4
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service',Center,Raleigh,NC 27699-1636
(gpm) RIG 24c.For Water Supply&Injection Wells:)m 13a.Yield Method of test:
PILLS Also submit-one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 30 - well construction to the county health department of the county where
constructed.
Fora GW-1 ' North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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