GW1-2021-03586_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 FROM
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519—A ft. ft.
NC Well Contractor Certification Number IS OUTER•:CASING for'multi-cased well§ OR-I;INER zt a 1.able )a
FROM TO DIAMETER THICKNESS I MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 130 ft 6.25 In- 1 #21 1 PVC
Company Name n Q 16ANNER CASING OR TUBING egther%nai closed,loo
2020—OO4HO FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt, in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. I in.
3.Well Use(check well use): Y7.'SOREEN,,,
Water Supply Well: FROM TO DIAMETER i SLOT SIZE THICKNESS MATERIAL
ft. ft. in,
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) 311csidential Water SuPPIY(single) ft. ft. in•
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
El Aquifer Recharge ❑Groundwater Remediation ,i]9:SANDIGRAIULPACK d.a "ifcabli_
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
rt. rt.
❑Experimental Technology ❑Subsidence Control
20:>DRILLING LOG'attacItadditional A666 if recess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 R. 30 ft. OVER BURDEN
04/05/2021 30 rt• 705 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location:
Joesph Tyson
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Glasgow Trail
Physical Address,City,and Zip 2I:'REMA
BUNCOMBE 07006856300000
County Parcel Identification No.(PiN) V,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one ladlong is sufficient)
N W 6
11 AA 08/20/2021
Signature of Certl Well Contractor Date
6.Is(are)the well(s): ❑✓Permanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or FlNo copy ofthis 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 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
8.Number of wells constructed: 1 construction details. You may also to
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 705 (ft.) 24a. For All Wells: Submit this:form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(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,
(ft.)
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
ll.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: 4
(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
1
13a.Yield(gpm)
1-1/2 Method oftest:
RIG 24c.For Water Supply&Injection Wells:
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.
Forth GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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