GW1-2021-00169_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:
14. ES
GARRETT CLYDE BANKS FROM ER 'to
FROM f0 I DESCRIPTION
ft. ft.
Well Contractor Name
4519-A `t
NC Well Contractor Certification Number 15.OUTER CASING(Coe multi-cased H'elJs)OR LINER if a Geable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 51 ft- 6 1/8 i" #21 PVC
Company Name 16.INNER CASING OR TUBING eothertnal closed-loop)
2021-00245 FRO" TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. i"•
List all applicable well permits(i.e.Countp,.State, Variance.Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
FROM TO DIAMETER , SLOTSIZE THICKNESS MATERIAL
Water Supply Well: ;",
ft. ft.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) in
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 rt. 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑1N9onitoring ❑Recovery
ft.
Injection Well: tt.
❑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 ❑Stonnwater Drainage rt. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION(color,hardness,soil/rock type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 �t 51 ft OVER BURDEN
11-11-2021 51 rt 805 ft GRANITE
4.Date Well(s)Completed: Well iD# ft.
5a.Well Location: ft. ft.
ROBT. DEWAYNE POLK
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1217 BEE TREE ROAD SWANNANOA, NC 28778
Physical Address,City.and Zip 2L REMARKS
BUNCOMBE 978070800400000
Countv Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lot/long is sufficient)
N W 0-A A A ho 11-22-2021
Signature of Ceru Well Contractor Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,I hereby cert fv that the wells)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 F]No cagy gfthis record has been provided to the well owner.
If this is a repair,/ill oat known well construction infornulion and erplain the nature o/7he
repair under#21 remarks section or on the back ol'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 ar non-water supply wells ONLY with the same construction,You can
suhmil one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 805 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For rnulliple wells list all depths it dilferent(example-3@200'and 2 c0100') construction to the following:
10.Static water level below top of casing: DRY (ft) Division of Water Resources,Information Processing Unit,
If itater 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 m 0 Method of test: RIG 24c.For Water Supply&Injection Wells:
(gp ) 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.
Fo,m GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013