GW1-2021-06056_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:
G 14.WATERZONES
arrett Banks
FROM TO DESCRIPTION
Well ContractorNanie ft. ft.
4519-A
NC Well Contractor Certification Number 15.OUTER CASING fortnulti-cased wells OR LINER if a`livable
FROM TO DIAMETER! THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 51 ft- 16.25 '-- 1 #21 PVC
Company Name 16.INNER CASING OR TUBING "eothermal closed-loop)
2020-00248 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. !in•
List all applicable trel/pernrhs(i.e.County,Stare,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) EIResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 fc. 51 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation `-19.SAND/GRAYEUPACK if applicable):'
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
a. tr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG:attach additionafsheets'if necessa
❑Geothennal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft, 51 ft. OVER BURDEN
6-9-2021 51 ft- 300 ft- GRANITE
4.Date Well(s)Completed: Well ID# ft. ft. "
5a.Well Location: ft. ft.
Cherise Hall ft. ft.
•r
Facility/Owner Name Facility ID#(if applicable) ft. ft.
108 Dog Star Lane Alexander, NC 28701 ft. ft. Pro
V
on P ,
Physical Address,City,and Zip 21.REAIARKS
Buncombe 9722187245
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(ifwell field,one lat/long is sufficient)
CU1Jl4 6-16-2021
N
Signature of Certified Well Contractor Date
6.Is(are)the well(s): GDPermanent or ❑Temporary By signing this jorm,1 hereby certify that the well(s)was(were)consinrcied in accordance
with I5A NCAC 02C.0100 or 15A NCAC;02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or KIND copy ofthis record has been provided to the well owner.
l/this is a repair,fill nor known ire//construction injormalion and explain the nature of the
repair under::21 remarks section or on the back of this 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.
Pbr muhiple injection or non-iraier supply wells ONLY with the same construction,you can
s'uhmit one form. SUBMITTAL INSTLICTIONS
9.Total well depth below land surface: 300 24a. For All Wells: Submit this'form within 30 days of completion of well
Pier muhiple wells list al/depths if'differeni(example-3@200'and tea 100) construction to the following:
10.Static water level below top of casing:
60 Division of Water Resources,Information Processing Unit,
(ft.)
I/water level is abore casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b. For Injection 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
1
13a.field(gpm) 20 Method of test: RIG
24c.For Water Supply&Irkiection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 30 well construction to the county health department of the county where
constructed.
Form G W-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013