GW1-2022-09468_Well Construction - GW1_20221017

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS FR WATER
ZQNES'
FRO\[ '1'O DESCRIPTION
Well Contractor Name ft. ft. {
4519-A
NC We]I Contractor Certification Number 15.OUTER CASING(for multi-med'wells)OR LINER(if a" Gcable)
FROM TO DIAMETER ' THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 57 ft- 16 1/8 ; in #21 1 PVC
Company Name 16.INNER:CASINGOR TUBING; eothermal closed-loo
2021-00645 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Couno,State.Variance,b jection,etc.)
ft. ft. in.
3.Well Use(check well use): `17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZF. THICKNESS MATERIAL
ft. rt. in.
❑Agricultural ❑Municipal/Public
in.
❑Geothermal(Heating/Cooling Supply) £]Residential Water Supply(single)
❑In(lustrial/Commercial ❑Residential Water Supply(shared) 18:GROUT i
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑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 ft. ft.
❑Aquifer Test ❑Stonmwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach addifional,sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21Remarks) 0 ft. 57 ft. OVERBURDEN
9-7-2022 57 ft. 205 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft. ,
5a.Well Location:
Archie Smith
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Curtis Creek Road Candler, NC 28715 ft. ft.
OCT 1 .
Physical Address,City,and Zip 21.REMARKS
Buncombe 8686408468
County Parcel Identification No.(PM)
5b..Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(il'well field,one]at/long is sufficient)
N W 9-9-2022
Signature -rCertt eftWell Contractor Date
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6.Is(are)the well(s): ❑O Permanent or ❑Temporary Br signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with I SA 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 ONo coPy gfthis record has been provided to the well owner.
lfthis is a repair,fill out known well construction iti/brrualion and erplain the nature ofthe
repair under#21 reorarks 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 saute construction,you can
.arhmit aru.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 nudtiple irells list all depths ifdijferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 30 (ft,) Division of Water Resources,Information Processing Unit,
lfwater level is above eating,rise"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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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 t11is.form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(-.pm) Method of test:
7 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: 20 well construction to the county health department of the county where
constructed.
Porn:GW-I North Carolina Department of Environment and Natural Resources—Division of Water Re'sotirees Revised August 2013