GW1-2021-06058_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD' For Internal use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS "FR.WATER ZONES • ,,:_
OM .TO DESCRIPTION
Well Contractor Name ft' ft'
4519-A ft. ft,
NC Well Contractor Certification Number 15.OUTER"CASING'foi..multr-cased wells ORLINER;ifa" licable
-FROM TO DIAMETER THICKNESS MATERIAL.
CLYDE SAWYERS & SON WELL &PUMP INC +1 ft. 77 ' fL 6:25 n. #21 PVC.
Company Name :1t+.:Il!iNER CASI�z lG t)R 7 UBING eotliermal;elosed-too
2020-00546 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:- in•
List all applicable well permits(i.e.County,Stare, Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17:SOR
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) 'lResidential Water SuPPIY(single) tt ft. in. ,
-
❑Industrial/Commercial ❑Residential Water Supply(shared) 18`GROTTY = '. '. 9=' .. ' �' %_ •, :,-
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 f. 20 . rt. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Reinediation 19:SANWGRAVUL PACK
FROM TO. MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery El Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
°',,20..Dlii MNGL G attach additloiialilu ets ifnecess •.. ,
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness,soil/rock type,grain size,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 77 fL OVER BURDEN
06/11/2021 77 ft- 185 fL GRANITE
4.Date Well(s)Completed: Well ID# ft. fL
5a.Well Location:
Newfound Creek Enterprises' ft. rt. NJ
Facility/Owner Name Facility ID#(if applicable) y
ft. fL
27 Pilgrims Path Lane
Physical Address,City,and Zip 21.REMARKS E
BUNCOMBE 9711197458
County Parcel Identification No.(PIN) UNu
0
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
N N 06/14/2021
Signature ofc. Well Contactor, Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby certifv 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 E]No copy o(this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature of the,
repair under#21 remarks section or on the back of thisform. 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.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: 30 Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail ServicelCenter,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
13a.Yield(gpm) Method oftest:
20 RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
PILLS well construction to the county health department of the county where
13b.Disinfection type: Amount: 2� �
constructed.
Forst GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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