GW1-2021-03584_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
`1"ATER.ZONES
GARRETT CLYDE BANKS EFROMTO DESCRIPTION
Well Contractor Name 4519-ANC Well Contractor Certification Number .CASING"foFmuitt:case NW_R1[s ,m, ,TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 tt. 90 ft. 6.25 #21 PVC
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Company Name 16,•INNERCASIlYG"ORTUBING "eithermalclosed
2020-00356 FROM TO DIAMETER THICKNESS " MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. fL in.
3.Well Use(check well use): €
,17.SCREEN;;" „
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
R. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) FIResidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT,1.; .;, _ .'.
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation ft. ft.
0 20 Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation NDIGRA L PACK MATERIAL Ie EMPLACEMENT METHOD
FROM L •,,:,. _ e, �s ,.,.,,,
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft, ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20'DRILLINGIOG attach'addlbona[sheets if necess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,g rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 90 ft. OVER BURDEN
05/05/2021 90 ft 645 tt GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Seth Solesbee
Facility/Owner Name Facility ID#(if applicable)
ft. ft. ,yam
Pole Creasman ft. ,
Physical Address,City,and Zip 21°REMARKS,:
BUNCOMBE 962641651400000
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)
N nAA Sig6 08/20/2021
nature ofcem Well Contractor Date
6.Is(are)the well(s): ❑✓Permanent 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 ENO cop},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 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 one form. c C SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 645 (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 2@100') construction to the following:
10.Static water level below top of casing: 30 (g,) 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:
(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) 2 Method of test: RIG 24c.For Water Supply&Injection Wells:
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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 countywhere
constructed.
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Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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