GW1-2021-06060_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 F -WATER ZONES,
ROM TO DFSCIUPTION
Well Contractor Name ft. ft.
4519-A ft. ft. i
NC Well Contractor Certification Number 1.5.OUTER CA4SING(for E1tJ.-caVVlJs)?aLfNER i.fiolicable)
FROM T DIAM TRI KNE� MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 185 ft- 16.25 i in- 1 #21 1 PVC
Company Name 16.INNER CASING OR TUBING(oothermall closed400li)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 2020-00408 in.
List all applicable well permits(i.e.County,State.Variance,hyection,etc.) ft ft in.
3.Well Use(check well use): A7;SCREEN„,�
'41
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
im
OAgricultural OMunicipal/Public
in.
ElGeothermal(Heating/Cooling Supply) ElResidential Water Supply(single)
ElIndustrial/Commercial DResidential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
01rrigation 0 ft' 20 ft- Bentonite Pumped
Non-Water Supply Well:
OMonitoring DRecovery
Injection Well:
ElAquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK if applieable)
OAquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Test OStormwater Drainage
oExperimental Technology OSubsidcncc Control 20.DRILLING,LOG(attach additioi.ialsheets if recess ad).,
OGeothennal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soiltrock type,grain sin,etc)
DGeothermal(Heating/Cooling Return) E10ther(explain under#21 Remarks) 0 85 ft OVER BURDEN
4.Date Well(s)Completed: 06/28/2021 Well tD# 85 245 GRANITE
5a.Well Location:
R & S Investments
Facility/Owner Name Facility ID#(if applicable) ft.
16 Indian Paintbrush
Physical Address,City,and Zip
it.REMARKS.";;:
BUNCOMBE 972118346
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifleation
(if well field,one]at/long is sufficient)
N W *A 06/28/2021
U QM
t;�W'Lcel�i Well Contractor Date
6.Is(are)the weU(s): R]Permanent or OTemporary By signing this form,I hereby certifv that the well(s)was(were)constructed in accordance
with IJA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or KNo cop),of this record has been provided to the well owner.
If1his is a repair,fill out known well construction information and explain the nature qf1he
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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,van can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 245 —(ft') 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i(different(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,
If water level is above casing,use"+ 1617 Mad 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
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ROTARY 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) 18 Method of test: RIG 24c.For Water Supply&Injectid:It Wells
Also submit one copy of this f66 within 30 days of completion of
13b.Disinfection type. PILLS Amount: 20 well construction to the county he'alth department of the county where
constructed.
Forffl GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resource, Revised August 2013