GW1-2021-00141_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS 14.
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number 1S.OUTER CASING for multi-easedrweUS)OR LINER if a '6eable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 78 ft. 6 1/8 i" #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
2019-00426 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): 47.SCREEN I
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in;
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Cooling Supply) EIResidential Water Supply ft. ft. in..
( l� b PP Y) PP Y
❑Industrial/Commercial ❑Residential Water Supply 18.GROUT
pp y(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft. Bentoriite Pumped
Non-Water Supply Well:
rt. rt.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwatcr Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/mck type,grain sae,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 78 ft. OVER BURDEN
6-21-2021 78 it 505 ft GRANITE
4.Date Well(s)Completed: Well ID#
tt. tt.
5a.Well Location:
LILY PITSUL rt. ft. DEC 13 2021
Facility/Owner Name Facility ID#(if applicable) ft. ft.
5 STONE VALLEY DRIVE CANDLER, NC 28715
Physical Address,City,and Zip 21.REMARKS
BUNCOMBE 8687348516
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
N N 7-5-2021
Signature of certt Well Contractor Date
6.Is(are)the well(s): 2 Permanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 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 copy ofthis record has been provided Id the well owner.
If 1hi.s is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 remarks section or on the back o(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 saute construction,you can
Submit one/o,uz SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 505 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i/di/jerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of easing: 80 (ft.) Division of Water Resources,Information Processing Unit,
If ualer level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
i
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 m 30 Method of test: RIG 24c.For Water Supply&Injection Wells:
(gP ) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 35 well construction to the county h1 alth department of the county where
constructed.
Forth GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013