GW1-2021-03580_Well Construction - GW1_20210823

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
4 M.WATER ZONES
GARRETT CLYDE BANKS '. ..
FROM TO DESCRIPTION
Well Contractor Name ft. it.
4519-A ft. ft.
NC Well Contractor Certification Number 15.SOUTER CASING for multi-cased+wells OR7dNER if:a"ticable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 193 ft 6.25 in. 1 #21 1 PVC
Company Name 16.INNER CASING OR TUBING 'eothermal closed-too
2021-00354 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: tt. tt. in.
List all applicable well permits(i.e.County,State,Variance,h jection,etc.)
ft. fL in.
3.Well Use(check well use):
„?17.SCREEN--
Water Supply Well: FROM TO DIAMETER SLOT S17.E THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Muni cipal/Public
❑Geothermal(Heating/Cooling Coolin Supply) E lResidential Water Supply ft. ft. in.
M i� g PP Y) PP Y
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO J MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/GRAVEL PACK it a liciblc.
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwatcr Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20:DRILLING LOG attach addition8l`sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,son/mck type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 R. 93 ft. OVER BURDEN
08/16/2021 93 ft 205 it• GRANITE
4.Date Well(s)Completed: Well ID#
ft. tt.
5a.Well Location:
Buncombe Land Holdings
Facility/Owner Name Facility ID#(ifapplicable) a
ft. ft. t1
9 Spring Dr., Lot 3
Physical Address,City,and Zip
p2L REMARKS`',,l'; `
BUNCOMBE 96283344720000to'�' .o
Z\ e>!,
County Parcel identification No.(PiN) e J`
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
N Woft A 08/16/2021
Signature of Cem Well Contractor Date
6.Is(are)the well(s): RIPermanent or ❑Temporary By signing this form,I hereby certifv 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 o(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 on the back of thisform. 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 one form. 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 ifderent(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 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: M
(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
30 test: RIG 24c.For Water Supply&Injection t
13a.Yield(gpm) Method of Wells:
Also submit one copy of this form within 30 days of completion of
PILLS well construction to the county health
13b.Disinfection type: Amount: 20 department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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