GW1-2021-06059_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 14.FROM
PTIOFROM "1'O DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number FRO UTER CASING for TRW-eaased wells OR LINER ifrs licable'
R THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 90 ft 6.25 in. #21 PVC
Company Name ,A6.INNER;CA'SINGORTUBING eothermatclosed400
2020-00438 FROM TO DIAMETER THICKNESS MATERLAL
2.Well Construction Permit#: e. tt. in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 77.SCREEN
z
Water Supply Well: FROM TO DIAMETER I�•�SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) it. tt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT F.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 it• Benton'ite Pumped
Non-Water Supply Well:
tt. ft.
❑Monitoring ❑Recovery
Injection Well:
❑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.DWLLiNG'I OG attach additibi0sheets if necessar
❑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' 90 f[' OVER BURDEN
06/23/2021 90 ft- 445 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Jason Davis ft. f[. ..
Facility/Owner Name Facility ID#(if applicable) ft. ft.
36 Carlabrese Lane
Physical Address,City,and Zip 21.'REMARICS
BUNCOMBE 869719971000000
County Parcel Identification No.(PIN) VV
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one]at/long is sufficient)
N W 06/24/2021
Signature,f`Cer1_Rt6 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 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or END 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 ofthe
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 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:445 tft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 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 Resource's,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
12 RIG 24c.For Water Supply&Injection Wells-
13a.Yield(gpm) Method of test: i
Also submit one copy of this form within 30 days of completion of
PILLS well construction to the county iealth department of the county where
13b.Disinfection type: Amount: 20
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Watei Resources Revised August 2013
i