GW1-2022-07616_Well Construction - GW1_20220817

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Cnntractor Information:
GARRETT CLYDE BANKS 1aR.zi ..<5 �. : 6: r , 4
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft. j
NC Well Contractor Certification Number f5 XJl11,LR4 Ittfx.lor'inulttc'a§eiliv[Is-l)R LiT� ,ilia lii Atli "'
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 70 ft- 161/8 #21 PVC
Company Name lull{YER<C11V(,OI2T3t371yCN, 'eoth¢imAllctose �„ "
2021-00179 FROM 10 DIAMETER THICKNESS MATERIAL
2,Well Construction Permit#: ft. rt. ' in.
List till applicable w t!ll permits(i,e.County,State,Variance,Injection,etc.
in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER, SWTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) E'lResidential Water Supply(single) ft. ft' in.'
❑lndustrial/Commercial ❑Residential Water Supply(shared) Nit R',0T?MMMI
FROM I TO MATERIAL EMPLACEMENT METHOD&.4MOUNT
ElTi-rigation 0
t[
Non-Water Supply Well: 20 ft' Bentonite Pumped
ft. tt.
❑Monitoring ❑Recovery
injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 29;SA'NDIGRA�?kL1' CKs d'a '°P;,hie , x " N
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrmk type. ram size,etc.)
❑Geothermal Heating/CooGn Return ❑Other(explain under#21 Remarks) 0 ft• 70 fr• OVER BURDEN
06-20-2022 70 fr• 285 fr• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location:
rt. rt.
JOSEPH MELTON/SCHUMACHER
Facility/Owner Name Facility ID#(ifapplicable) f
STARRY NIGHT COVE LEICESTER, NC ft. ft AUG G
Physical Address,City,and Zip yy�� ii[[ r
tl.".lit lYlao�gam,� .,v,. ..k
BUNCOMBE 87804272790000 Flr^+.r'1�_z` r g UPS
County Pat-eel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)N `,l, 06-28-2022
Signature of Cerh Well Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary
By signing Neic(n•m,!Trerehr rrrttj}�that the Nell(s)was/were)constructed in actnrdanre
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofihis record has been provided to the well owner.
ff this is u repair,fill uut knuwn well construction informatiun and ex7daiu the nature of the
repair under#21 remark section or on the hack r'1his li,rm. 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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. 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 hTths ifdi/fi rent(example-3(V00'and 2(a.-100') construction to the following:
10.Static water level below top of casing: 20 (ft) Division of Water Resources,Information Processing Unit,
uter level is above casing.use"+^ 1617 Mail Service Center,
If w 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.c.auger,rotary,cable,direct push,etc.)
Division of Water Resources,lUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)
30 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: 16 well construction to the county he lth department of the county where
constructed.
i
Fort%G W-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013