GW1-2022-10120_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This firm can be used for single or multiple wells
I.Well Contractor Information:
GARRETT CLYDE BANKS FROM ERzO
FROM TO DESCRIPTION
Well Contractor Name
4519-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wens OR LINER(ifa lieable
FROM TO DIAMETER , THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 48 ft. 6 1/4 ' #21 PVC
Company Name 16.INNER CASING OR TUBING eothermalsclosed400
2022-002`+8 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: V ft• ft. I in.
List all applicable well permits(i.e.Couno,,State. Variance,htjec:ion,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) ElResidential Water Supply(single) ft. ft. in•
❑Industrial/Commercial ❑Residential Water Supply(shared) I8 GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft' 20 it- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVELTACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
ft. tt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets ifnecessa '
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 8 ft. OVER BURDEN
9-21-2022 48 ft- 265 ft- GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Christina Fisher ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
11 Douglas Drive Leicester, NC 28748 f.
Physical Address,City,and Zip 21.REMARKS,
Buncombe 97004694280000 ola�ls5tya'�WQ
Coumv Parcel Identification No.(PIN) D1 3Oo
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification;
(if well field,one lot/long is sufficient) T_�f
N W 10-28-2022
Signature of Cent Well Contractor Date
6.Is(are)the well(s): ❑✓Permanent or ❑Temporary Br signing this Jorm,l hereby certify 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 copy gf1his record has been provided to the well owner.
If this is a repair.Jill out known well construction inJbrmation and explain the nature ofthe
repair under#21 remarks section or on the hack of thisJorm. 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 hells constructed: 1 construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-water supple wells ONLY with the same construction,you can
submit one form. GC SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dt(jerent(example-3 a 200'and 2@ 100') construction to the following:
10.Static water level below top of casing: 20 Division of Water Resources,Information Processing Unit,
if it 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
I
13a.Yield(gpm) 50 Method of test: RIG
24c.For Water Supply&Injection!Wells:
Also submit one copy of this form within 30 days of completion of
13h.Disinfection type: PILLS Amount: 30 we!I construction to the county health department of the county where
constructed.
Foram GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013