GW1-2021-00166_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 lF RRWATERZDNES
ODI "1'O DESCRIPTION
Well Contractor Name
ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased'.VOHS)OR LINER(if a Gcable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft 123 ft 6 1/8 in. #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2021-00241 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. tn•
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 I'O DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. it.
❑Agricultural ❑Municipal/Public
(single) ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water SuPP1Y
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 rt. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑1`v1 on itori ng ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater 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/rock type,gmin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 123 ft OVER BURDEN
11-2-2021 123 r`' 225 ft GRANITE
4.Date Well(s)Completed: Well ID# f•.
5a.Well Location: ft. ft.
Robert Kuykendall ft. ft. '
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Webb Creek Road Fairview, NC 28730 rt.
I'hysical Address,City.and Zip 21.REMARKS
BUNCOMBE 9676264460
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one]at/long is sufficient)
11-16-2021
N W
Signature ofCer6 Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary Br,signing this form,I hereby certij,that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0I00 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or KNo cone ofthis record has been provided fa the well owner.
/l'thiv is a repair.fill out known well construction inlorntalion and explain the nature ofthe
repair under#21 rentarks 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.
For nutltiple injection at wells ONLY with the satne construction,i on can
sahmil One form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
I'm nnthiple rrel/s list all depths ifdifferent(example-3@200'and 2 til100') construction to the following:
10.Static water level below top of casing: 40 (ft) Division of Water Resources,Information Processing Unit,
lhrcuer level is above casing,use••+" 1617 Mall 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
10 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 30 well construction to the county health department of the county where
constructed.
Furor GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013