GW1-2021-06488_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Garrett Banks 14.WATER ZONES
,
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING:for multi-cased wells)OR LINER if a "licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 68 ft. 6.25 in. 1 #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2021-00053 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
Li.0 ull applicable hell permti.s(i.e.County.Slate,Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) KIResidential Water Supply(single) f. f. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑h-rigation 0 ft- 20 ft- Bentonite Pumped
Nun-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHODft. tt.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG°(attach additional'sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soit/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 68 ft. OVER BURDEN
9-15-2021 68 1r• 185 1r• GRANITE
4.Date Well(s)Completed: Well iD# ft. ft.
5a.Well Location:
Sandra Biddix
rt. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Old Leicester Hwy Leicester, NC 28748 ft. ft.
Plrvsical Address,City.and Zip 21.REMARKS t
Buncombe 97102889300 Informatnl r®
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) 0� __aa..�
-t N W Je-&%1�cx GaA.14& 9-16-2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
By signing this form, l hereby certify that the+re!/(.rJ was(were)construc•!ed in accordance
+rtih 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 ONo cow ojthi.s record has been provided to the+re//owner.
I/this is a repair.fill out kno+rn+rell con.sirucnon int6nnation and evplatn the nature of the
repair under 21 remarks.section or on the back q/'thi.+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.
I,or nudtiple injection or nun-u mer supply+fells ONLY+rich the same construction,you can
suhinn one/in•nn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Por nu/iiple hells list all depths i/di//ereni(example-3 a.200'am/2«100') construction to the following:
10.Static water level below top of casing: 30 (1t) Division of Water Resources,Information Processing Unit,
//a tiler love/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) 20 Method of test: 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.
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Form G W-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013