GW1-2021-06472_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS `
FROM TO DESCRIPTION
Well Contractor Name
4519-A
NC Well Contractor Certification Number U fbenul as
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 1- 44 ft 6.25 in. #21 PVC
Company Name N6R MIN fUB]N_. _ E_ ,
2021-00286 FROM DIAMN; ER THICKNESS MATERIAL
WOMEEM
2.Well Construction Permit#: fr. fr. in.
List all applicable u-ell permits 6.e.County,State,Variance,Injection,etc.) ft ft in
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. Ct. in.
❑Geothermal(Heating/Cooling Supply) EJResidential Water Supply(single) fr. ft. in.
❑Industrial/Commereial ❑Residential Water Supply(shared) ~D
FROM TO MATERIAL EMPLACEMENT METHOD&AM. OUNT
❑hTi ation 0 fc• 20 fr Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well: 11. ft.
❑Aquifer Recharge ❑Groundwater Remediation
FROM TO MATERIAL ENPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stornrwater Drainage
❑Experimental Technology ❑Subsidence Control
D,
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillruck tv a gnin size,etc.)
❑Geothermal Heatin Coohn Return ❑Other(explain under 921 Remarks) 0 ft 4 fr OVER BURDEN
08/10/2021 44 ft 185 fr GRANITE
4.Date Well(s)Completed: Well ID# ft ft
5a.Well Location: ft. ft.
BRANDON HENSLEY ft. fr. CEIVED
Facility/Owner Name Facility ID#(ifapplicable) 2�L1
R. ft. I i I ]
OLD NC HWY 20 LOT # 2 ft. ft.
Physical Address,City,and Zip
BUNCOMBE 971232412700000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient)
N Wn AA 10-01-2021
Signature of CeA Well Contractor Date
6.is(are)the well(s): (]Permanent or ❑Temporary y fy ( /
B si min b•this nrm.l herehv tern that the NeII,Y)was 6'e/'e constructed in accordance
With i5A NCAC 02C.0100 or 1 SA NCAC 02C.0200 11'ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or PJNo copy of this record has been provided to the well ouwer.
If this is a repuir,fill out knonw well construction informatiun and explain the nature of the
repair under#21 remarks section or on the hack oJ7his form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.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 iftliJferenl(example-3(000 an 2(a'100') construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
II'uuter level is above 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 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: constriction 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
m 13a.Yield
(gP ) 100 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: 25 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013