GW1-2022-07613_Well Construction - GW1_20220817

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS .14.
FRWATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number 15.-OUTER:CASING for multi-csised�Us)TO LINER(if:a licable)'
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 162 ft- 16 1/8 ' #21 1 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2021-00477 FROM I TO DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#: ft. rt. in•
1_ist all applicable well permits(i.e.Counn',State.Variance,Injection,etc.)
ft. I ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
-❑Geothermal Heating Cooling Supply) El Residential Water Supply(single) ft. ft. in.
( � b PP Y) PP Y( g )
❑Industrial/Commercial ❑Residential Water Supply(shared) is:GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft, Bentonite Pumped
Non-Water Supply Well:
rc. rt.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Cifapplicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwatcr Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20,DRILLING LOG attach additional sheets if necessar
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/mck type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 62 ff• OVER BURDEN
6-18-2022 62 ft- 305 ft- GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Brandon King
Facility/Owner Name Facility ID#(if applicable) ft. ft. KEGE'1
Old NC 20 Hwy Leicester, NC 28748 ft. ft.
Physical Address,City,and Zip 21.REMARKS,," ., .: <,. '1022
Buncombe 971297820300000
County Parcel Identification No.(PIN) j., t
3&ri,�1BOGs
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one tat/long is sufficient)
N W 6-30-2022
Signature ofCertt Well Contractor l Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary Br signing this form,I hereby cert4[ 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 EINo copy gfthis record has been provided to'the well owner.
iJ ltis is a repair.Jill out known well construction injormation and explain the nature of the
repair under#21 remarks section or on the back ol'thisform. 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 iniectian or non-water supply wells ONLY with the save construction,you can
submit one.(nrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple"ells list all depths il'QJerent(example-3 et 200'and 2 a 100') construction to the following:
10.Static water level below top of casing: 30 (rt•) Division of Water Resources,Information Processing Unit,
(/hater 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(gpm) Method of test:
20 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.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013