GW1-2021-06482_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 F4.wATERzoil�s _ Y
FROM TO DESCRIPTION
PTION
Well Contractor Name ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number IS.OUTER CAGING for multi-cased:wells O$iL1NER it a liealile a
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 l" 65 ft- 6.25 in- #21 PVC
Company Name "36.INNER CASING OR TUBING eothermal'closed4oa
2021-00040 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. I
in.
List all applicable well permits(i.e.County,State.Variance,b jection,etc.) ft. ft. in.
3.Well Use(check well use): 1.7:SCREEN ?; . "' �_-;
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water SuPPIY(single) f• ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20 'L Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ;,19.SAND/GRAVEL PACK if applicable),
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwatcr Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additioahl sheets if-oecess
[]Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION eolor,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft- 65 ft. OVER BURDEN
07/15/2021 65 ft 405 ft• GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location:
Melanie Pitrolo ft. rt.
Facility/Owner Name Facility ID#(if applicable)
238 Medford Br. Rd., Lot 3B ft
Physical Address,City,and Zip s° -, t�
REMARKS: .
BUNCOMBE 8695153666 nl Seciion
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)
N N1^1 A 07/15/2021
Signature orCerth Well Contractor Date
6.Is(are)the well(s): 17Permanent or ❑Temporary By signing this form,I hereby certifv that the well(s)was(were)constructed in accordance
with I5A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No copy of 1his 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 attach additional pages if necessary.
For multiple injection or non-water sripp(v wells ONLY with the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 30 (ft•) Division of Water Resources,Information Processing Unit,
If 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.Yield(gym) Method of test:
4 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.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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