GW1-2021-00143_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
GARRETT CLYDE BANKS 14.
FROM '1'O DESCRIPTION
Well Contractor Name
ft. ft.
4519-A f`
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER(if a dcable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 80 ff• 61J8 #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2021-00390 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable Hell permits(i.e.County,State, Variance,Injection,etc)
ft. f[. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIn1,
ft. ft. in.
❑Aericultural ❑MunicipaUPublic
in.
❑Geothermal(Heating/Cooling Supply) ]Residential Water Sup IY(sin(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 it• 20 ft- 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 ❑Stormwater Drainage
ft. it.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiltrock type,gnin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 it• 80 ft. OVER BURDEN
11-30-2021 80 it 305 it GRANITE
4.Date Well(s)Completed: Well ID#
t
5a.Well Location:ROBERT NELON ft. ft. DEC 13 2021
Faciiity/Owner Name Facility iD#(if applicable) ft. ft.
96 LITTLE BO LANE LEICESTER, NC 28748
Phvsical Address,City,and Zip 2'.REMARKS
BUNCOMBE 970048821800000
Countv Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one hat/long is sufficient)
12-2-2021
N W rm�l r vvv;— fA
Signature of Certt Well Contractor Date
6.Is(are)the well(s): 2 Permanent or ❑Temporary Br signing this form,1 herebtl certfv that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo coPy gfthis record has been provided to the well owner.
If this is it repair.Jill out known well construction information and explain the nature of the :.
repair under#2/remarks section or on the back of'thisform. 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 ifnecessary.
For nudtiplc injection or non-water supphv wells ONLY with the sane construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdyferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:40 (ff) Division of Water Resources,Information Processing Unit,
1f 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(gpm) 3 Method of test: RIG
24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13h.Disinfection type: PILLS Amount: 30 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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