GW1-2021-06111_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Intemal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
14.Garrett Banks FROM WATER ZONES DESCRIPTION
Well Contractor Name
4519A
NC Well Contractor Certification Number 15,OUTER CASING for multi-cased wells 0 1 LINER if a livable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 60 ft- 16.25 #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2021-00037 FROM J TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
Lict all upplic-able hell permits(i.e.Couniv,Seale,Ilarianc•e,hyec•lion,etc)
ft. ft, in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrrioation 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 a livable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft. I
❑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,soiltmck e, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fit- 60 ft. OVER BURDEN
5-18-2021 60 f`• 305 ft- GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft. +�
Conrad Clark Builders LLC ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. •1
28 Stocksville Ridge, Weaverville, NC 28787 ft. ft. '�
Phvsical Address,Citv,and Zip 21.REMARKS
Buncombe 9745959977 :���`
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(it\yell field one lat/long is sufficient)
N W IR"It - 5-24-2021
Signature ofCertitied Well Contractor ! Date
6.Is(are)the well(s): 21Permanent or ❑Temporary By,signing dais form, l hereby certify that the uvell(s)was(uyere)constructed in accordance
with 15A NCAC 02C.0/00 or 15A NCAC 02C.0200 Well Consiruclion Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy ofthis record has been provided to the iveU owner.
ll this is a repair,.lill out known well constructlon in/nrmation and explain the nature gl'the
repair under-1 rauarks sectiott or on dte back(?I lhisJbrnt. 23.Site diagram or additional welfdetails:
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.
kor multiple injeclion or non-water supply wells ONLY frith the,ante construction,you can
.suhtuil one limn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
/,for tutduple hells list all depdts t/'di/Jvreni(example-3@200'and 2@/00') construction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
I/'traler level is above casing,use" Center,Raleigh,NC 27699-1617
1617 Mail Service
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) 6 Method of test: 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: 30 well construction to the county health department of the county where
constructed. !
i
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013