GW1-2021-03587_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
zi4°WA"TER�OAIEB,......-- -.-
FRObt '1'O DESCRIPTION
Well Contractor Name ft. ft. I
4519-A
NC Well Contractor Certification Number 15;OUTER'(ASING for multrcased}YCEES'..OR-::LINER'iI a 1[ca61e
FROM TO DIAMETER I THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rc. 104 ft 6.25 #21 PVC
Company Name 16.INNERVA$ING,DIt!TURJNG= Ylib" at closed Iptf F
2021-00052 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. ft. in.
3.Well Use(check well use): 1I $(kREEN. - °ftw..
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
in.
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in,
❑lndustrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. it.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation �',,,"14'._'8AND/GRA'VEL:PACI
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control .,
20.DRILLiNG�"'I oG attach additional'iheets if-necess ........ .... .. »,
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 tt, 104 it OVER BURDEN
05/25/2021 104 ft 165 ft GRANITE
4.Date Well(s)Completed: Well ID#
ft. tt.
5a.Well Location:
e�d
B & B Developers
Facility/Owner Name Facility ID#(if applicable)
Spring Oak Ct., Lot 11
ft. ft.
Physical Address,City,and Zip
21AEMARKS.11.i:
BUNCOMBE 879020891400000
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)
08/20/2021 N W
Signature ofCertr 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 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E!]No 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 an 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 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: 165 (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 1@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
11.Borehole diameter: 6.25 (in.) 24b.For Iniection 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) 12 Method of test: RIG
24c.For Water Supply&Injection[Wells:
Also submit one copy of this form within 30 days of completion of
PILLS well construction to the county health department of the countywhere
13b.Disinfection type: Amount: 20
constructed.
i
Fonn GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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