GW1-2022-10119_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This firm can be used for single or multiple wells
1.Well Contractor information:
GARRETT CLYDE BANKS FROM WATER FROM
£'
F'RW1 "1'O DESCRIPTION
Well Connector Name
fr. ft.
4519-A ft. ft. I
NC Well Contractor Certification Number 15.OUTER CASING((for multi-eased i4ells)IORLINER(if a' ticable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft, 87 ft. 6 1/4 i!' #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop),
8697054092 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
1_ivt till applicable well permits(i.e.County,State. Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑rrrigadon 0 rt. 20 ft- Bentonite Pumped
Non-Water Supply Well:
rt. rt.
❑NI on itori ng ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft. ,
❑Aquifer Test ❑Stonmwater Drainage L
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.'DRILLING LOG(attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/mck type,grain size,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 87 rt. OVER BURDEN
10-25-2022 87 ft- 205 ft- GRANITE
4.Date Well(s)Completed: =Well ID#
rt. rt.
5a.Well Location: ft. ft.
Cynthiane Morgenwech ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Nov ]A 0 2022
37 Friendship Lane Candler, NC 28715 ft. ft. �Dn Pmass Oo urea
Phvsical Address,City,and Zip 21.REMARKS
Buncombe 8697054092
COL111tV Parcel Identification No.(PIN) ,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
61'well field,one lat/long is sufficient) __0.4
11
N N 10-31-2022
Signature ofCerti Well Contractor Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary Br signing this form,i herebv certiJv 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 ElNo cony gf1his record has been provided to the well owner.
If IN.,is a repair,fill nut known well construction inlbrmation and twi lain the nature n(the
repair under#21 remarks section or on the back ofthis,Jorm. 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 ifnecessary.
For wuhiple infection or nun-t+uter.supplr wells ONLY with the same construction,you can
snbnrit nee%nrrn. 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
17nr nadtiple nrlls list all depths rjdiftrent(example-3 n 200'and 2@100') construction to the following:
10.Static water level below top of casing: 40 ((t) Division of Water Resources,Information Processing Unit,
I/voter level is above casing,use"+- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in-) 24b.For lniection 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.) i
Division of Water Resources,! Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 Method of test: RIG
24c.For Water Supply&Injection)Wells:
Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: PILLS Amount: 20 well construction to the county health department of the county where
constructed.
Folm GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013