GW1-2021-06078_Well Construction - GW1_20210809

i
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.VVATERZo ZONES I _
FROM 'I'O DESCRIPTIO PTION
Well Contractor Name ft. ft.
4519-A ft. ft. j
NC Well Contractor Certification Number I5.OUTER CASING for multi cased-wells ORLINER if a Iicable..
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 84 ft 6.25 ` in• 1 #21 1 PVC
Company Name 16.INNER CASING OR TU$ING eothermal closed-loop)
2020-00560 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: C7 ft. rt. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. fL in.
3.Well Use(check well use): A7.SCREEN
Water supply Well: FROM To DIAMETER SL07'SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(sin(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 1" 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
rt. e.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additions`(sheets if:necess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 84 ft. OVER BURDEN
07/01/2021 84 et• 505 rt• GRANITE
4.Date Well(s)Completed: Well ID#
rt. rt.
5a.Well Location:
Audrey Marshbanks Brown
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
59 Farm Life Ridge rt. 02
Physical Address,City,and Zip 21.REMARKS
BUNCOMBE 9756409516 caesstn9
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N N 07/01 H2021
Signature -f Certi Well Contractor Date
6.Is(are)the well(s): ZPermanent or ❑Temporary Br signing this form,I hereby certifv that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or END copy gf1his record has been provided to the well owner.
ff this 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 this form. 23.Site diagram or additional wellAetails:
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 supp(v wells ONLY with the same construction,you can -
submit oneform. 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 multiple wells list all depths ifdifferent(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,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I1.Borehole diameter. 6.25 (in.) 24b. For Infection 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
i
13a.Yield(gpm)
15 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.
i
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
I