GW1-2021-00142_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.WATER ZONES'
FROM '1'OI DESCRIPTION
Well Contractor Name ft. ft.
4519-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a hcable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 65 ft- 6 1/8 in. J #21 1 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
MCM-222W 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): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
`❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑firi ation 0 n• 20 rt• Bentonite Pumped
Non-Water Supply Well:
n. n.
❑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 ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness,soillrock type,grain size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) 0 ft- 65 rt. OVER BURDEN
8-12-2021 65 ft- 165 ft• GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location:
AMANDA MANN ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. (t.
WESTMORELAND CIRCLE CANTON, NC 28716
Physical Address,City,and Zip 21.REMARKS
BUNCOMBE 8667-56-8276
Countv 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) __H_
8-20-2021
N W
Signature ofCert—M6 Well Contractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this form,1 herebv certify that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy gfthis record has been provided to'the well owner.
//'this is it repair,fill aw known well construction inforntalion and explain the nature of the
repair wider#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.
ror multiple injection or non-water sttpplr wells ONLY with the same construction,you can
sahmil one fnnn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 165 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi(ferent(example-3@200'and 2 cil100') construction to the following:
30 Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: (ft)
If itaier 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: r
(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) 7 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.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013