GW1-2021-06489_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 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 THICKNESSI MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 94 fl• 6.25 #21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2021-00254 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable ireN permits(i.e.County,State, Variance,Injection,elc•.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/CoolingSupply) ❑Residential Water Supply(single) ft. ft. in.
pP Y) PP Y
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 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)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquiter Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20..DRILLING LOG'attachadditional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sailim k type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 94 ft. OVER BURDEN
9-3-2021 94 ft, 505 ft- GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft.
Christopher Masters ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
137 D&J Lane Leicester, NC 28748 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Buncombe 9703064716 in Unit
County Parcel Identification No.(PIN) MNR nor Section
51b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field.one lat/long is sufficient)N W n,�_�=4r; ' LA 9-3-2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this jbrm,I hereby certify that the we//(s)was(were)constructed in accordance
with I5A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofthis record has been provided to the we//owner.
//'this is a repair/ill out known well construction information and explain the nature oj7he
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.
h'or multiple injection or non-uwter.supply wells ON/,Y with the same construction,you can
suhntit one jbrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 505 24a. For All Wells: Submit this form within 30 days of completion of well
1•or multiple we/h list an depths ifdillerent(example-3 c@200'and 2 rt 100') construction t0 the following:
10.Static water level below top of casing: 80 (ft.) Division of Water Resources,Information Processing Unit,
(j 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.field
(gpm) Method of test:
1.5 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: 35 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