GW1-2021-06113_Well Construction - GW1_20210809

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WELL CONSTRUCTION RECORD
For Internal Use ONLY: �
This form can be used for single or multiple wells
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1.Well Contractor Information:
GARRETT CLYDE BANKS 14.FROMWATERZ(O PTI01
FROM TO DESCRIPTION ;
Well Contractor Name
4519-A
NC Well Contractor Certification Number 1S OUTER CASING for multi-eaie8 wells OR LINER if a'"licable
FROM I TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 52 It. 6.25 In• ` #21 1 PVC
Company Name 16.INNER CASING OR7`13BING, "eo4hermal closed-too
2021-00097 FROM TO DIAMETER THICKNESS MATERIAL
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): t7.SCREEN:,, ' . �. ^' v �e� . '
Water Supply Well: ft ft FROM TO DIAMFTERt
In. SLOT S17.E THICKNESS MATERIAL
❑Agricultural ❑Muni cipal/Public
❑Geothermal(Heating/Cooling Supply) FResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.,GROUT •
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20 ft. Bentonlite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20 DRILLING'LOG attach additional sheets if�necess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soil/rock type,gnin size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 52 ft. OVER BURDEN
07/01/2021 52 ft. 305 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Cole Riddle LLC ' -
ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
32021
27 Walnut Ridge Lane, Mars Hill ft. rt.
Physical Address,City,and Zip 21.REMARKS 1:
BUNCOMBE 973396017700000 ,ISecY;on
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one IaVlong is sufficient)
N `I 07/07/2021
Signature o f Cem Well ContracMtor Date
6.Is(are)the well(s): 21'ermanent or ❑Temporary By signing this form,I hereby certifv 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 of this record has been provided to the well owner.
Ifthis 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 thisform. 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 oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfd erent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 (ft•) Division of Water Resources,Information Processing Unit,
Ifwater 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) Method of test:
6 RIG 24c.For Water Supply&Injection Wells:
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Also submit one copy of this form within 30. days of completion of
136.Disinfection type:
PILLS Amount: 20 well construction to the county health department of the county where
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013