GW1-2022-02863_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD For Internal Use ONLY: RECEIVED
�+`M— ���
This form can be used for single or multiple wells 5 @.E I�' Ij°'°"6,.,F
1.Well Contractor Information:
14:,WATER:ZONEs..
GARRETT CLYDE BANKS
FROM TO DESCRIPTION
Well Contractor Name ft. ft. i Inform-Aict t Pri?;;c,avi,;�; Ur.f
4519-A ft. ft. i r
NC Well Contractor Certification Number `8 OUTER'CASING forilmultrease Mwells'OR L1NER'if a 'livable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 51 ft- 6 1/8 ',In- 421 PVC
16 INNEAr SING=OR:Ti}BING keathermafclosed Company Name .„�%,r•
2021-00387 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17:SCREENS
Water Supply Well: FROM 'to DIAMETER SLOT SIZE THICKNESS MATERIAL
'.
❑Agricultural ❑Municipal/Public in
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) •;18:
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation %f9:SANDIGRAYEL"PACK'°if a licatile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20:DRIL1 IIVGaI OG attach additiiina(,sheits'lf aecess s
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,ctc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 51 tt. OVER BURDEN
12-13-2021 51 fI• 605 ft GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Logan Hayze Atema
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
29 Woodsey Lane, Swannanoa
Physical Address,City,and Zip
BUNCOMBE 060839194300000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifrcation:
(if well field,one lat/long is sufficient)
N 12-14-2021
Signature of Certl Well Contractor Date
6.Is(are)the well(s): 21'ermanent or ❑Temporary By signing this form,1 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 well: ❑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 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: 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 oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 605 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 25 Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1L 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 m 3 Method of test: RIG 24c.For Water Supply&Injection Wells:
(gp ) Also submit one copy of this form within 30 days of completion of
PILLS well construction to the county health department of the county where
13b.Disinfection type: Amount: 30
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013