GW1-2021-01187_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATERZONES
Jarrett Banks
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number 15,OUTER CASING I'for multi-cased wells'OR LINER ifa p"licahle
FROM TO DIAMETER THICKNESS1 MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 68 ft 6.25 #21 PVC
Company Name 16.INNER CASING.ORTUBING(geothermal dosed-loop)
2020-00566 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable hell permits(i.e.County,Slate,Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial []Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recover), ❑Salinity Barrier ft. ft.
❑Aquiter Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG tattach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soillrack type,grain sin,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 68 ft. OVER BURDEN
2-17-2021 68 ft. 225 ft- GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
C Solesbee LLC A k-� c =_
ft. ft' 'l '� i; .:
Facility/Owner Name Facility ID4(ifapplicable) ft. ft.
McKenna Hill Lot 1 Lane Candler, NC 28715 1t. 1t. ,AR
Phvsical Address,City,and Zip 21.REMARKS
Buncombe 8696884547 liit4.,i;�';,'>-1t
County Parcel Identification No.(PIN) Z''° ``l
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W SISLt{t �jO n�Cla^ 3-4-2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this farm,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofdtis record has been provided to the well owner.
lfil i.s is a repair,fill out known well construction inlbrmation and explain the nature ofthe
repair under 2l remarks section or on the back gfthis firm. 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.
Ibr multiple injection or non-water supply wells ONLY with the sane construction,you can
cubma one lirrm. SUBMITTAL INSTLiCTIONS
9.Total well depth below land surface: 225 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
Vor nnthiple wells list all depths i/'differenl(example-3@200'and 2 a/00') construction t0 the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
i/'water lerel is above casing,use"f" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b. For Iniection Wells ONLY: In addition to sending die 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) 20 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 22 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