GW1-2022-02861_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor information:
GARRETT CLYDE BANKS FR WATER ZONES
FROM I DESCRIPTION
Well Conn actor Name ft. ft. s - ^^^'T ilk
4519-A
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased':wells)OR LER lieablel
FROM TO DIAMETER THICIN if a KNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 1130 ft 6 1/8 1 in. 1 #21 1 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2021-00441 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt. in.
List till applicable well permits(i.e.County,State. Variance,h jection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERAA1,
in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling-Supply) ]Residential Water SuPP1Y(single) ft. it. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
El Irrigation 0 ft. 20 rt• Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑NI on itoring ❑Recovery
Injection Well:
❑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
ft. rt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,gnin size,etc.)
❑Geothermal(Pleating/Cooling Return) ❑Other(explain under#21 Remarks) 0 R• 130 ft• OVER BURDEN
12-10-2021 130 e• 285 ft• GRANITE
4.Date Well(s)Completed: Well iD# ,
f ft.
Sa.Well Location: ft. ft.
PISGAH VIEW HOLDING ft. ft.
Facility/Owner Name Facility ID#(if applicable) it. ft.
72 CHEROKEE ROAD CANDLER, NC 28715
Phvsical Address,City,and Zip 21.REMARKS
BUNCOMBE 961893077300000
COlmty 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) -ifA
N W0-- -'^1 A 12-16-2021
Signature ofCertr Well Contractor Dale
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this Jbnn,I hereby ccr•ti(b that the well(s)was(were)constructed in accordance
With 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constriction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy gfthis record has been provided to-the well owner.
//'this is a repair,Jill out known well construction inlornalion and e.rplain the:nature ofihe
repair ander#21 remarks section or on the back oJ'thisJorm. 23.Site diagram or additional we11 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 nahiple injection or non-water.supp/v wells ONLY with the scone construction,You can
submit 011e,fan,,, SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 285 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiftrent(example-3 eJ200'and 2@100') construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
It water level is above Casing.Ilse"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I L.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 tenter,Raleigh,NC 27699-1636
13a.Yield m 7 Method of test: RIG 24c.For Water Supply&Injection Wells:
tgp ) Also submit 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 GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013