GW1-2022-05085_Well Construction - GW1_20220526

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 ERZo tEs �:_ -
FROM TO DES CR1PTION
Well Contractor Name ft. ft.
4519-A
NC Well Contractor Certification Number 15.,OUTER CASING(for multi-cased,wells)OR LINER if a licable
FROM TO DIAMETER; THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 162 ft 6 118 in. 1 #21 PVC
Company Name 16.INNER CASING OR TUBING eothelwat closed-loop)
2022-00105 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. 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: 7GROUT
TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. in.
❑Agricultural ❑MunicipaVPublic
❑Geothermal(Heating/Cooling Coolin Supply) ❑Residential Water Supply(single) ft. in.
� � g PPY) PPY( � g )
❑IndustriaVCommercial ❑Residential Water Supply(shared) TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft, ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge El Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
tt. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG`attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 tt' 62 ft. OVER BURDEN
05-03-2022 62 ft- 305 ft. GRANITE
4.Date Well(s)Completed: Well ID#
tt. ft.
5a.Well Location:
Joshua Campbell
Facility/Owner Name Facility ID#(if applicable)
218 Pinner Rd
9
Physical Address,City,and Zip 21.REMARKS is
Buncombe 9643067476000 _
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 05-12-2022
Signature flcertt Well Contractor Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with I SA 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 copy of this record has been provided to the well owner.
f
1 repair, out known well construction information and ex this is a re i lain the nature o the
p f th ram or additional well details:p f 23.Site diagram repair under#11 remarks section or at the back of this form. g
You may use the back of this page to provide additional well site details or well
S.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 saute construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface• 305 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing: 25 Division of Water Resources,Information Processing Unit,
Ifwater 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 subunit 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) Method of test:
4 RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form 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