GW1-2021-00168_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This lot in can be used for single or multiple wells
1.Well Contractor information:
GARRETT CLYDE BANKS 14.WATER ZONES
ft�r
DESCRIPTION
Well Contractor Name4519-A ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LiNER(if a Iieabb`
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 24 ft- 6 1/8 i #21 PVC
Company Name 16.INNER CASING OR TUBING cothermal closed-too
2021-00277 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List till applicable well permits(i.e.Coungt State. Variance,Injection,etc.) ft. ft.
in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZ.F, THICKNESS MATERIAL
ft. ft. in.
❑Aw_ricultural ❑Municipal/Public
ft. ft. In
❑Geothennal(Heating/Cooling Supply) OResidential Water SuPP1Y(single)❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 fc. 20 rt. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
ft.
Injection Well: ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquiter Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwatcr Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothennal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness,soilirock type,grain size,etc.
❑Geothennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 R' 24 it OVER BURDEN
11-16-2021 24 1105 ft GRANITE
4.Date Well(s)Completed: Well iD#
5a.Well Location: ft. tt.
LEE & LONNIE GREAWALT
1
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
KNOB VIEW TRAIL SWANNANOA, NC 28778 fc. ft.
Physical Address,City,and Zip 21.REMARKS
BUNCOMBE 968939471400000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
N w
11-22-2021
Signature of Cent Well Contractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this form,I hereby certi i-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 well: ❑Yes or KNo cony gflhis record has been provided to4lhe well owner.
//ihis i.c a,viouir Jill oul known well consiruclion infornmlion and ewplain the nature of the
repair under#21 remarka 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 inieetian or non-waer supp/r wells ONLY with the sane construction,You can
suhndi One/brill. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 1105 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple❑•ells list all depths ifdi(ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing-. DRY (ft) Division of Water Resources,Information Processing Unit,
If wrbreh 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) 0 Method of test: RIG
24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13h.Disinfection type: PILLS Amount: 35 well construction to the county health department of the county where
constructed.
Forin GW-I North Carolina Department of Environment and Natural Resources—Division of Water,Resources Revised August 2013