GW1-2021-06486_Well Construction - GW1_20211027

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
GARRETT CLYDE BANKS F4.WATER.110 P TIO
FROM 1'O DESCRIPTION
Well Contractor Name ft. ft.
4519-A iL ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a livable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 f" 1210 ft 6 1/8 #188 1 Steel
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2021-00352 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: tt. ft. in.
List ill applicable well permits(i.e.County,State, Variance,11yection,etc.) in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER: SLOTSIZE THICKNESS MATERIAL
ft.❑Agricultural ❑Municipal/Public ft. in.
❑Geothermal(Heating/Cooling Supply) IFIResidential Water Supply(single) ft. ft. in.
❑htdustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM 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(it applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
rt. rt.
❑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- 210 ft. OVER BURDEN
10-12-2021 210 ft. 210 ft. GRANITE
4.Date Well(s)Completed: Well fD#
ft. ft.
5a.Well Location:
Bradford Rogers
Facility/Owner Name Facility ID#(if applicable)
143 Ridge Road Candler, NC 28715 rt. 021
Physical Address,City,and Zip 21.REMARKS
BUNCOMBE 869867161500000 fQ��ssm9
County Parcel Identification No.(PIN) Wi' UYR Secl%
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification- V I
(if well field,one lot/long is sufficient)
N W 10-20-2021
Signature ofCertt Well Contractor Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,1 hereby certify that the wel/(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consiniction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy gfthis record has been provided to the well owner.
It this is a repair,fill oul known well construction in/brntation and explain the nature of the
repair under#21 remarks section or on the back o/'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: 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 nnc.lbrm. SUBMITTAL►NSTUCTIONS
9.Total well depth below land surface• 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For muthiple wells list all depths i/df(lerent(exantple-3@200'and 2G100') construction to the following:
10.Static water level below top of casing: 50 (ft) Division of Water Resources,Information Processing Unit,
If tcater level is above casing.use"+•' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For ►niection 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) V
C Method of test: 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 countywhere
13b.Disinfection type: Amount: 30 constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013