GW1-2021-00138_Well Construction - GW1_20211213

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 ER ZONES'
FROM '1'O DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft.
NC Well Contractor Certification Number A.S.OUTER CASING for multi cased welts OR LINER it a' cable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 78 ft- 6 1/8 in. #21 PVC
Company Name 16.INNER CASING'OR TUBING eothermid closed-loop)
2021-00511 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: fL ft. in.
List all applicable well permits(i.e.County,State. Variance,b jection,etc.) ft. ft. in.
3.Well Use(check well use): ;,17.SCREEN ;.;:.,....,,
Water Supply Well: FROM 'I'O DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water SuPPIY(single)❑Industrial/Commercial ❑Residential Water Supply(shared) -18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Wefl:
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDItiRAVEL;PACK if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additionaCsheets'if necess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/mck type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 78 ft. OVER BURDEN
10-21-2021 78 ft• 345 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Keith Kuykendall
Facility/Owner Name Facility ID#(if applicable)
tt. ft.
76 Hemlock Ridge ft. IJLC 13 2
021
Physical Address,City,and Zip 21.REMARKS
BUNCOMBE 8772-14-2370
County Parcel Identification No.(PEN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
N w __0
6 n A A 11-29-2021
Signatti—re-ol'Cen7flKi Well Contractor Date
6.Is(are)the wetl(s): ©Permanent or ❑Temporary By signing this form,1 hereby certilv that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing weft: ❑Yes or ElNo 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 o/7he
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: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supphv wells ONLY with the same construction,you can
submit oneform. 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
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 25 (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
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) 3 Method of test:
RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this foim within 30 days of completion of
13b.Disinfection type: PILLS Amount: 30 well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013