GW1-2022-05925_Well Construction - GW1_20220627

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES'
GARRETT CLYDE BANKS FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A
NC Well Contractor Certification Number OUTER CASING'(for multi-cased wells ORSLINER if
a licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 150 ft- �61/8 in• #21 PVC
Company Name 16.INNER CASING OR TUBING eothermal:closed-loop)
2021-001 38 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. R, in.
List all applicable well permits(i.e.County,State,Variance,h jection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. rt. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20 it• Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 49:SAND/GRAVEL PACK if a 1kablc .
❑Aquifer Storage and Recovery ❑Salinity BarrierFROM TO MATERIAL EMPLACEMENT METHODft. tt.
❑Aquifer Test ❑Stormwater Drainage
ft. it.
El Experimental Technology ❑Subsidence Control
20:DRILLING LOG`(attach additional sheets it-recess -
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillroek type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 50 ft OVER BURDEN
06-09-2022 50 ft 745 ft _GRAfaU, E
4.Date Well(s)Completed: =Well ID#
Sa.Well Location:
Carl Richard Patton II rt. it.
Facility/Owner Name Facility ID#(if applicable)
36 Old Cove Rd. ""
Physical Address,City,and Zip 2 L REMARKS'
Buncombe 071100268200000
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification-
(ifwell field,one]at/long is sufficient)
NA 06-15-2022
SignattTr'e_ofCer1-ift0d Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby certify 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 fonnn. 23.Site diagram or additional well details:
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 same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 105 (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@1001 construction to the following:
10.Static water level below top of casing: 5 (ft.) 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 Injection 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) 100 Method of test: 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-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013