GW1-2021-06483_Well Construction - GW1_20211027

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 TO -
DESCRIPTION
Well Contractor Name
4519-A
3pthatc�jfl% r l ]f
NC Well Contractor Certification Number 0 a �*
FROM TO DIAMF,TF•R THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 43 ft- 6.25 #21 PVC
Company Name 1sTF1RStlt sylf te7)M
2021—002 Q 5 FROM DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: (J rt. ft. in•
List all applicable well permits(i.e.Counnt State,Variance,Injection,etc.) ft. ft. In.
3.Well Use(check well use):
Water Supply Well: FROM To I DIAMETER SLOT SIZE THTCKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. In.
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. tt. In.
❑lndustrial/Cotmnercial ❑Residential Water Supply(shared) R '
FROM TO M .A V_ MATERIAL EMPLACEENT METHOD& MOUNT
❑hTi ation Non-Water Supply Well: 0 It• 20 ft• Bentonite Pumped
ft. ft.
❑Monitoring ❑Recovery
injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
R. fr.
❑Experimental Technology Subsidence Control❑
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soiVrmk ri e pmin size,etc.
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 fr. 3 fr. OVER BURDEN
07/19/2021 43 ft• 145 fr GRANITE
4.Date Well(s)Completed: Well 1D#
ft. ft.
5a.Well Location: ft. ft.
BRANDON HENSLEY ft. fr.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. OCT
OLD NC HWY 20 LOT # 1 ft. ft. n un;
Physical Address,City,and Zip -
R �
BUNCOMBE 971232412700000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one IaUlong is sufficient)
N `I 10-01-2021
Signature of Ccili'Mff Well Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary y k b f fy U ( )
B si min�this nrm,/herehr reran lhu7 the wells was• were constructed in accordance
with 15A NCAC 02C A100 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 ofthis record has been provided to the well owner.
If this is a repair.fill out Anuim well construction infornmtiun and explain the nature of the
repair under#21 remarks section or on the back a(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 constructitm,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 145 -(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if diJJerent(example-3(u00 anr12(a 100') construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
If aaler 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) 20 Method of test: RIG
24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 20 well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013