GW1-2021-06110_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Garrett Banks 14.WATER ZONES r
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells O LINER if a" icable
FROM TO DIAMETER' R THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 130 ft- 6.25 #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2021-00180 FROM TO DIAMETER' THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. m.
l.i.si all applicable we//permits(i.e.('aunty,Slate, Variance,Injection,e1c.)
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
ft. in.
❑Geothermal(Heating/Cooling Supply) DResidential Water SuPPIY(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Olt-rigation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑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 ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20:•DRILLING LOG attach additional'sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soilimck type,gmin siu,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 30 ft. OVER BURDEN
5-20-2021 30 ft• 205 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
op
5a.Well Location:
Cassie Sue Dockery
Facility/Owner Name Facility ID#(ifapplicable)
292 Martin Ford Road Weaverville, NC 28787
Physical Address,City,and Zip 21.REMARKS - �r}tI:' " rOV
Buncombe 97238726640000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field one ladlong is sufficient)
N W � � - 5-25-2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form, I hereby certify that the well(s)was(were)constructed in accordance
wish 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 ofihis record has been provided to the we//owner.
ll dais is a repair,fill out known well construction in/imnation and explain the nature ojlhe
repair under'21 remarks section or on the hack gf1his farm. 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.
hhr muhiple injection or non-rater supply wells ONLY with the sane construction,you can
subino one jbrm. SUBMITTAL INSTLICTIONS
9.Total well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
1­-multiple we/Ls list a//deplits i/chlierent(example-3@200'and 2 ct 100') construction to the following:
10.Static water level below top of casing: 50 (ft•) Division of Water Resources,Information Processing Unit,
Il;rater level is above casing,use ' 1617 Mail Service Center,Raleigh,NC 27699-1617
r
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
13a.Yield(gpm) 4 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form'.within 30 days ofcompletion of
13b.Disinfection type: Amount: 20 well construction to the county health department of the county where
constructed.
i
Fonn G W-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013