GW1-2022-05090_Well Construction - GW1_20220526

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS F4.WATER ZONES
FRO\I TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if a Iicable)
FROM I TO DIAMETER I THICKNESS I MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 184 ft- 6 1/8 in. 1 #21 1 PVc
Company Name 16.INNER CASING OR TUBING(geothermal closed400
2021-00545 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable it-ell permits(i.e.County,State.Variance,L jection,etc.) ft ft in
3.Well Use(check well use): 17.SCREEN.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
tt. ft. in.
❑Agricultural ❑Municipal/Public
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) I7Residential Water SuPP1Y(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft' 20 ft. Bentonite Pumped
Non-Water Supply Well:
Ct. ft.
❑M.onitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier rt ft
❑Aquifer Test ❑Stormwater Drainage
ft. rt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional'sheets if hecessa -
❑Geothertrial(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rt 84 rt OVER BURDEN
rJ-2-2022 84 ft 405 rt GRANITE
3.Date Well(s)Completed: Well ID#
ft. ft.
Via.Well Location:
R&S Investments ft. ft.
Tq� t?a d t
Facility/Owner Namc Facility iD#(if applicable)
Indian Paintbrush Rolling Hills of French Broad Lot 55 Alexander
ft. rt. 7
Physical Address,City,and Zip 21.REMARKS
Buncombe
County Parcel Identification No.(PIN)
ib.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: -
22.Certification:
(if well field,one lot/long is sufficient)
N N 05-17-2022
Signature ofCem Well Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary Br signing this forin,I hereby certfv that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Mell Consu action Standards and that a
7.Is this a repair to an existing well: ❑Yes or i INo cope of this record has been provided to the well owner.
ll'thi.s Ls a repair,fill out known well construction infi nnation and explain the nature of the
repair under#21 remarks section or on the back o/'this•forin. 23.Site diagram or additional well details:
Yen 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 it jection or inn-truler.rnpph•wells ONLY with the sane construction,you can
suhnit onefarn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iI'QJe-cnt(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing• 60 (ft.) Division of Water Resources,Information Processing Unit,
{Jwater level is above casing,use"+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For injection 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 in
(gP ) Method of test:
4 RIG 24c.For Water Supply&Injection Wells:
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.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013