GW1-2022-02858_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD For Internal Use ONLY: � �.�
This form can be used for single or multiple wells <t--�.`a,•-e.
b
1.Well Contractor Information:
GARRETT CLYDE BANKS FROM
WATER ZONES ;
ROi•'1 "r0 FDESCRIPTION _
Well Contractor Name ft. ft.
y�f ; :.�sl I'rtiL Utt�t
4519-A
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(ifa 6cable)
FROM TO DIAMETER' THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 97 ft- 6 1/8 I 'in. #21 PVC
Company Name 16.INNER.CASING'ORTUBING eothermaLclosed-loo"
2021-00259 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State, Variance,Itiection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZF; THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. ft. in:
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 rt. 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
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20-DRILLING LOG attach additional sheets if necessar
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soit/rock type,gnin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 97 ft' OVER BURDEN
4.Date Well(s)Completed: 12-9-2021 Well ID# 97 e. 265 ft• GRANITE
ft. ft.
5a.Well Location:
Ronald Hilton ft. ft.
Facdiity/Owner Name Facility ID#(ifapplicable) ft. ft.
70 Cherokee Road Candler, NC 28715 ft.
Physical Address,City,and Zip 2'.REMARKS
BUNCOMBE 961893172500000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
6
N w 12-16-2021
Signature of Certr Well Contractor Date
6.Is(are)the well(s): ❑✓Permanent or ❑Temporary Br signing this forrn,1 herebv certifB 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 ql this record has been provided to the well owner.
I/this is a repair,fill out known moll construction information and cceplain the nature of the
repair wider#21 remarks section or on the back o/'this Jonn. 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 multiple injection or non-water supply ivells ONLY with the saute construction,you can
srdmrit arc.form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nn iliple wells list all depths it d;(jerent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
ll pater 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 ofthis form within 30 days of completion of we]]
12.Well construction method: construction to the following:
(i.e.auger.rotary.cable,direct push,etc.)
Division of Water Resources,iUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 Method of test- RIG 24c.For Water Supply&Injection Wells:
Also subunit one copy of this form within 30 days of completion of
13h.Disinfection type: PILLS Amount: 25 well construction to the county health department of the county where
constructed.
Form G W-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013