GW1-2022-05928_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:
GARRETT CLYDE BANKS F4.wATER.zONEs. rTI "
FROM TO DESCRIPTION
Well Contractor Name
ft.
4519-A rt.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased-wells OR LINER it:a `ticable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 72 ft- �61/8 421 PVC
Company Name 16.INNER CASING OR TUBING. eothermid closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 2020-00229 9 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): I7.SCREEN
Water Supply Well: FROM TO DIAMETER - SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) E IResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 rc. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a "Ifcable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING-LOG':attach additional-sheets if necess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type, rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 72 ft. OVER BURDEN
06-09-2022 72 rt• 125 rt• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft.
Douglas Douthitt
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Wilson Cove Rd. JUN 7 .
rl. rt.
Physical Address,City,and Zip i�„3.,;
Buncombe 968834274800000 21_REMARKS , �'�
il;il.ffU
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)
N `l 06-15-2022
Signature of Cert Well Contractor Date
6.Is(are)the well(s): RPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.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.
If this is a repair,fill out known well construction information and explain die 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 m•non-water supply wells ONLY with the same construction,von can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 125 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths rfdi erent(example-3@200'aid 2@100) construction to the following:
10.Static water level below top of casing: 5 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)
50 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.
Foram GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013