GW1-2021-06476_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:
14.WATERZONES
Garrett Banks .,
FROM TO DESCRIPTION
Well Contractor Name ft. ft. -
4519-A ft. ft.
NC Well Contractor Certification Number -15.OUTER CASING(for multi-cased wells OR-LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 188 ft. 6.25 i" #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2020-00532 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
all applicable well permits(i.e.C•outur,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 in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(sin(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 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 applicable)'
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑AyuiferTest ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG•attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 88 ft. OVER BURDEN
8-25-2021 88 ft• 345 ft' GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft.
Victoria Lancaster Ames ft. ft.
r
Facility/Owner Name Facility ID#(ifapplicable) PT
ft. ft.
344 Hookers Gap Road Candler, NC 28715 ft. ft. 11
• �process .
Physical Address,City,and Zip
21.REMARKS
Buncombe 8699722062
County Parcel Identification No.(PIN)
5h.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field one[at/long is sufficient)
N W &Wy - 8-30-2021
Aa Signature of Certified Well Contractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this Jorm, I hereby certify that the well(s)was(irere)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 ElNo copy ofthis record has been provided to the ire//owner.
ll llus is a repair,fill out knoirn ire//c•onslruc•tion inlonnotion and explain the nature glthe
repair under 2/retnarks sec lion or on the back q/7his Jura 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.
1,or mulliple injection or non-hater supply irel/.s ONLY with the same construction,you can
submil one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 345 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Vor multiple ire/h list all depths ij'dijjerenl(example-3 a@200'and 2 c@100') construction to the following:
i
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
(/lrmer level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.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
13a.field(gpm) 20 Method of test: RIG
24c.For Water Supply&Injection1wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:
PILLS Amount: 35 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