GW1-2021-06115_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 FROM
WATER ZONES DESCRIPTION
Well Contractor Name ft. ft. f
4519A ft. ft.
NC Well Contractor Certification Number 15.OLITER CASING for multi cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. so fr• s.25 421 PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2020-00241 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
Us/all applicahle•well perntit.r(i.e.C ounill,Stale,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.
❑Agricultural ❑Municipal/Public
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) I311esidential Water Supply(single)
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
ft.
Injection Well: ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer"rest ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
❑Geothermal(HeatinJCooling Retum) ❑Other(explain under#21 Remarks) 0 f`• 50 ft. OVER BURDEN
5-27-2021 50 f` 225 f`• GRANITE
4.Date Well(s)Completed: Well ID# ft• ft.
5a.Well Location: ft. ft.
Amy Garrison ft. ft.
Facility/Owner Name Facility ID'(ifapplicable) ft. ft.
105 IVY Hill Road Weaverville, NC 28787 ft. ft.
Physical Address.City.and Zip 21.REMARKS \R
13
Buncombe 9755866332 pto • o�
County Parcel Identification No.(PIN) -O\\J� �t4AA`k
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient) aa
N w 'basylktt 6-2-2021
Signature ofCertitied Well Contractor Date
6.Is(arc)the w'ell(s): ©Permanent or ❑Temporary BY signing this form,I herehy c•ertyjj,that the wel/(s)was(were)constructed in accordance
with 15A N'AC 02C.0I00 or 15A NCAC 02C.0200 Well Construction,Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo cop,gfdus record has heen provided to the well owner.
11'dti.c i.c a repair,fill out known well construction igl6mralion and explain the nature of'lhe
repair order 21 rentarkv seclion or on/he hack ajdris fitrnt. 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.
/vn'mulople injection or nun-walersupply wells ONLY with the.same construction,you can
submil one jinn. SUBMITTAL iNSTL1CTIONS
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
/,or rtuthiple wells list all dep/hc i/'ai j#erenl(example-3 ct 200'and 2,@100') construction to the following:
10.Static water level below top of casing:
50 Division of Water Resources,Information Processing Unit,
(ft.)
/f water le re/is ahore casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b. For Iniection Wells ONLY:! In addition to sending die 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.field(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: 20 well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 201