GW1-2021-00147_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 F4.VVATER "to
FROM 'f0 DESCRIPTION
Well Contractor Name
4519-A ft. ft.
NC Well Contractor Certification Number 15.rOUTER CASING for multi-cased wells)OR LINER(if a ticable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 51 ft- 61/8 #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed400
2021-00071 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Count,,State, Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SGREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling/Cooling Supply) El Residential Water Supply(single) ft. ft. in•
( g b PP Y) PP Y( � g )
❑Industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft• 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK MATERIAL
FROM AL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20:DRILLING-LOG(attach additional-sheets if necessary)_
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 f' 51 tt OVER BURDEN
10-8-2021 51 ft 465 ft GRANITE.
4.Date Well(s)Completed: Well ID#
5a.Well Location: ft. tt• DEC 13 2021
JULIA HAMER ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. tt.
WESTVIEW DRIVE LEICESTER, NC 28748
Physical Address,City,and Zip 21.REMARKS
BUNCOMBE 9701-51-2336
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification
(ifwell field,one hat/long is sufficient)
10-21-2021
N W
Signature ofCert"iTIta Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certgJ 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 FlNo copy gf1his record has been provided lathe well owner.
11'1hi.s is a repair.fill out known well construction inlbrmation and erp/ain 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 ifnecessary.
For multiple injection or non-water supply wells ONLY with the sane construction,you can
cuhina one loan. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 465 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths il'differeut(example-3 a 200'and 2 c0100') construction to the following:
10.Static water level below top of casing: 120 Division of Water Resources,Information Processing Unit,
(ft.)
4 water level is above casing,use'+" 1617 Mail Service CIenter,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 24aabove, also submit a copy oflthis 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) 1 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: 35 well construction to the county health department of the county where
constructed.
Fong GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013