GW1-2021-06484_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:
44.WATER ZONES
GARRETT CLYDE BANKS FROM De SCW-IPTION"'
Well Contractor Name ft.
4519-A ft. ft.
NC Well Contractor Certification Number _15.OUTER CASING for LINER I ao licable)
'q eased V's'?E THICKNESS
FROM TO TR..A_.iT_1R_ T MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. 1139 ft 16.25 #21 1 PVC
Company Name 16.INNER CASING OR TUBING(g6f&rmal closed-too0"'
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 2021-00189 ft. ft. in.
List all applicable well permits(i.e.County,State.Variance.Injection,etc.) ft. fL in.
3.Well Use(check well use); W.SCREEN,,
Water Supply Well: FROM TO DIAMETEW SLOTS17E THICKNESS MATERIAL
DAgricultural OMunicipal/Public ft. ft. in.
DGeothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft• ft. in.
1:1 Industriat/Commercial OResidential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ClIrrigation 0 20 ft- Bentonite Pumped
Non-Water Supply Well:
DMonitoring EIRecovery
Injection Well:
OAquifer Recharge CGroundwater Rernediation 19.SAND/GRAVEL PACK if applicabltil'
OAquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ElAquifer Test DStormwater Drainage
ElExperimental Technology ElSubsidence Control
20.DRILLING attach
LOG(aach additional sheets if necessary��'­
,
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grein size,etc)
OGeothermal(Heating/Cooling Return) E10ther(explain under#21 Remarks) 0 ft 139 ft OVER BURDEN
09/16/2021 139 265 GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location:
Brandon King
Facility/Owner Name Facility lD#(if applicable)
334 Dix Creek #1 Rd., Lot # 6 ft.
Physical Address,City,and Zip 2
1.REMARKS
BUNCOMBE 9619277941
County Pared Identification No.(PIN) D\NR
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification-
(ifwell field,one lat/long is sufficient)
N %A J 09/16/2021
Signature of Well Contractor --*-,W Date
6.Is(are)the we][11(s): BPermanent or ElTemporary By signing this form,I 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 wefl: E]Yes or END copy of this record has been provided to the well owner.
If 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 well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 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 oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 265 -(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 (ft.) Division of Water Resources,Information Processing Unit,
If water 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
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ROTARY 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) 10 Method of test: R I G 24c.For Water Supply&InjectioniWells
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