GW1-2022-10133_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
14'W"TERZONEs
GARRETT CLYDE BANKS l
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
4519-A ft. ft. E
NC Well Contractor Certification Number 15.'OUTER CASING(for'multi-casedwells)ORLINER(ifa` lieable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 77 ft• 6 v4 #21 1 PVC
Company Name 16 INNER CASING OR TUBING eothermal closed-loo
2022-00024 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft in.
List all applicable well permits(i.e.Couny"Slate. Variance,injection,etc.)
ft. fL 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
❑Gcothernial(Heating/Cooling Supply) i7Residential Water Supply(single) ft. ft. in.;
❑Industrial/Commercial ❑Residential Water Supply(shared) t8.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑AgLiiferRecharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK:ifa lieable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20:-DRILLING LOG'attach'addi8onallsheets if necessary):
❑Geothermal(Closed Loop) ❑TIaceI FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
[]Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) 0 ft' 77 ft• OVER BURDEN
10-11-2022 77 ft• 505 ft• GRANITE
4.Date Well(s)Completed: Well iD#
tt. tt.
5a.Well Location:
Benjamin Whittle
Facility/Owner Name Facility ID#(ifapplicable)
74 Morgan Hill Road Fairview, NC 28730 ft.
Physical Address,City,and Zip
21.REMARKS
Buncombe 0616903344 o ursil
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one]at/long is sufficient)
N W 11-3-2022
Signature ofCertu Well Contractor Date
6.Is(are)the well(s): ❑✓Permanent or ❑Temporary By signing this form,I herebv certify that the well(s)was(were)constructed in accordance
with 15A N(:AC 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.
//'Ibis is a repair.Jill oul known well construction inlirrnralion and erplain the nature o0he
repair under#21 remarks section or on the back q(this.1brm. 23.Site diagram or additional well details:
You may use the back of this page tto provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For InIthiple injection or norr-waler.supph•we Us ONLY with the scone construction,um can
sol„r,il one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 505 (ft.) 24a. For All Wells: Submit this,form within 30 days of completion of well
For nm6iple wets list all depths il'dt/ferent(example-3@200'and 2C100') construction to the following:
10.Static water level below top of casing: 60 Division of Water Resources,Information Processing Unit,
l/iiatvr level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY: inraddition 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 m 5 Method of test: RIG 24c.For Water Supply&Injectioli Wells:
(gp ) Also submit one copy of this forrii within 30 days of completion of
13h.Disinfection type: PILLS Amount• 20 well construction to the county health department of,the county where
constructed.
Poraei GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
t