GW1-2021-06109_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS FR:VFtATERzoNEs
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number ;15.OUTER CASING,, foamultrcased wells OR 1>INLR`if a licable ..
FROM I TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 it. 52 it 6.25 in #21 PVC
Company Name I&INNER CCASING OR TUBING'('eotlieruial rIc sed-loo`)',_'
2021-00140 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt. 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 DIAMETER SLOT SIZE THICKNESS MATERIAL
in.
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single)
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 20 ft- Bentonite Pumped
Non-Water Supply Well:
tt. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation :19..SANDIGRAYELPACK(if a'"licable ...
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
26.`DRILLINQLOG attach addltiiinal sbeets;if pecess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiltrock type,g rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)J 0 ff 52 ft. OVER BURDEN
05/14/2021 52 ft 205 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Walter Daniels III
Facility/Owner Name Facility ID#(if applicable)
ft. ft. •/ f� 2
36 Poor Mans Hollow, Leicester
Physical Address,City,and Zip t
2t.REMARKS.,, : 91
BUNCOMBE 96095216050000 i sly 'p��►C� ��
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one]at/long is sufficient)
N 05/17/2021
Signature ofCeil-iftIff Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,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 ONo copy ofthis 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 ofthis 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 ifnecessary.
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: 205 (ft.) 24a. For All Wells- Submit this form within 30 days of completion of well
For multiple wells list all depths ifili ferent(example-3@200'atd 2@100') construction to the following:
10.Static water level below top of casing: 30 (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 jCenter,Raleigh,NC 27699-1636
i �
13a.Yield(gpm) Method of test:
6 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: 20 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