GW1-2021-00165_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.WATER .110
FROM I'O DESCRIPTION
Well Contractor Name ft. ft.
4519-A r`
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if a 6cable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 84 rt• 6 1/8 i" #21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2020-00352 FROM TO DIAMETER THICKNESS MATERIAL .
2.Well Construction Permit#: f[. ft. I in.
List all applicable well permits(i.e.Counh•,State. Variance,/ejection,etc.)
f[. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIA1,
in:
❑Agricultural ❑Municipal/Public
❑Ceothermal(Heating/Cooling Supply) E IResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 rt. 20 rt. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft, ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonrtwater Drainage
I]Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer R
TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) 84 f[ OVER BURDEN
11-5-2021 165 ft GRANITE
4.Date Well(s)Completed: Well ID#5a.Well Location: ft.
REBEKAH STIFFLER ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
56 CREEK RUN ROAD CANDLER, NC 28715 ft. ft.
Phvsical Address,City,and Zip 21.REMARKS
BUNCOMBE 8698111504
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification
(if well field,one lat/Imng is sufficient)
rs,', CIM&V1 J 11-10-2021
N W r vVV 0A
Signature ofCeriihL4 Well Contractor Dale
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,l hereby certi i that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NC'AC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or F1No copy gflhis record has been pror•ided to the well owner.
If this is a repair,till out known well con.strntclion in/in'ntalion and explain the nature of the
repair under#21 renrrrrks section or on the back ojthis 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.
Fur multiple injection or non-wale)supply wells ONLY with the sarue construction,you can
subuit onelbrin. 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 4 diOcrent(exantple-3 n 200'and 2G100') construction to the following:
10.Static water level below top of casing. 25 (ft.) Division of Water Resources,Information Processing Unit,
i/faster 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) Method of test:
RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this foim within 30 days of completion of
13h.Disinfection type: PILLS Amount: 20 well construction to the county health department of the county where
constructed.
. Fora GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013