GW1-2021-06114_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
14'WATER ZONES
Garrett Banks FROM TO DESCRIPTION
Well Contractor Name ft.
4519-A
NCWzIIContractorCertificationNumber 15OLITER.CASING.formulti-casedwells OR:LINER.if applicable)
FROM TO DIAMETER: THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 48 ft- 16.25 #21 1 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)___
FROM TO DIAMETER THICKNESS
2.Well Construction Permit#:
2020-00317 ft ft in.
MATERIAL
List till applicable well perntit.v(i.e.County,State,Variance.Injection,etc)
ff. 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) KIResidential Water SuPPIY(single) f. ft. in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL` EMPLACEMENT METHOD&AMOUNT
El Irrigation 0 " 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 Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness soil/rock type,gmin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft. 48 ft. OVER BURDEN
5-14-2021 48 l" 505 fit' GRANITE
4.Date Well(s)Completed: Well[D# ft. ft.
5a.Well Location: ft. ft.
R&S Investments ft. ft. io
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Rolling Hills of French Broad Alexander, NC 28701 ft. ft. 21
•1
Plivsical Address,Citv,and Zip 21.REMARKS
Buncombe 9721163720 r� cesst�a�J
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification: J
(dwell field,one]at/[on,is sufficient)
N W 612%, :i 3ot.�.t� 5-18-2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this torn(,l hereby certify that the well(.O was(were)constructed in accordance
with 15A NCAC 02C.0/00 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is(Iris a repair to an existing well: ❑Yes or FINo copy ofthis record has been provided to the weH owner.
if this is it repair,Jill out known well construction iglbrmation and explain the nature gf'ihe
repair under=21 remarks.section or on the back q/7hi.s jbrn. 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: construction details. You may also attach additional pages if necessary.
1•hr multiple injection or non-water supply wells ONLY with the sane construction,you can
submit onetorn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 505 (ft.) 24a. For All Wells: Submit this iform within 30 days of completion of well
Vor nulliple welly list all depths ifcli/jereni(example-3@200'and 2 a l00') construction to the following:
10.Static water level below top of casing: 1 00 (ft) Division of Water Resources,Information Processing Unit,
l/hater 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 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.) j
Division of Water Resources,.Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gp ) 24c.For Water Supply&Injection Wells:
m 2 Method of test: RIG
Also submit one copy of this form within:30 days of completion of
13b.Disinfection type: PILLS Amount: 35 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