GW1-2022-05927_Well Construction - GW1_20220627

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS 1 FROM WATERzoivEs :'..
OM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells TO LINER if a' licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 fc. 56 ft. 6 1/8 1n #21 1 PVC
Company Name 16.-INNER CASING OR TUBING eothertnal closed400
2022-00114 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +ft
ft. in.
List all applicable well permits(i.e.County,State,Variance•hyection,etc.)
ft. in.
3.Well Use(check well use): la,SCREEN '
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft.❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Coolin Supply) EIResidential Water SuPP1Y(single) ft. tt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO J MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 tt. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remcdiation 19.SAND/GRAVEL'PACK_if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier
FROM
ft. TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
.20.DRILLING LOG attach additiotiaCsheets if uecess
❑Geothermal(Closed loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) 0 ft- 56 ft. OVER BURDEN
05-25-2022 56 ft• 205 ft• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Conrad Clark
Facility/Owner Name Facility ID#(if applicable) J U N
ft. ft.
16 Stocksville Ridge
Physical Address,City,and Zip 21.REMARKS ``"' r a✓ a, (I
Buncombe 9745969333
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: &22.Certio4fleation:(ifwell field,one ladlong is sufficient)N 06-16-2022
Signature Contractor Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Constriction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks 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 multiple injection or non-water supply wells ONLY with the same construction,von can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 25 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+•• 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection 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
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.
Forth GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013