GW1-2021-03579_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS 4:WATERZANES ..:F . . .. .... . w u.x.m ._.... . .,,.....
FROM TOL DESCRIPTION
Well Contractor Name ft. ft.
4519-A
I
NC Well Contractor Certification Number t5.OUTER CASING for ca multised we[Is LINER ifa icable
FROM TO DIAMETER' THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 87 ft 6.25 � i" #21 PVC
Company Name ,, 16-.7NNER'C', ING OR TUBING iro"Oelvial closed-400 "'
2021-00372 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: tt. ft, in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
in.
3.Well Use(check well use): Ia."SCREEN
Water Supply Well: FROM TO DIAMETER ! SLOT SIZE THICKNESS MATERIAL
ft. rt. in•'
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. rt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.CROIIfi,,,,
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hTi ation 0 tt. 20 ft• Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19:SAN0/GRAVEL PACK if a llcable. .`.-
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
211:1)RILLINGrI0G attach additronei,slieetsYif oecess" _„ ra`.
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 tt. 87 rt. OVER BURDEN
08/16/2021 87 ft 205 ft GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Buncombe Land Holdings A ,
Facility/Owner Name Facility ID#(if applicable) ft. ft. O
11 Spring Dr., Lot 2 rt. rt.
Physical Address,City,and Zip
2I.REMARKS—'—''
BUNCOMBE 96283353390000 `
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
N N 08/16/2021
Signature ofCem Well Contractor Date
6.Is(are)the well(s): ❑�Permanent or ❑Temporary By signing this form,I hereby certifv that the wells)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 E!lNo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or our the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.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: 205 (ft.) 24a. For All Wells: Submit this:form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 1@100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
If water 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
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)
30 Method of test: RIG 24c.For Water Supply&Injection(Welis:
�
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 20 well construction to the county health department of the county where
constructed.
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Forf GW-1 North Carolina Department of Environment and Natural Resources—Division of water Resources Revised August 2013
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