GW1-2022-07621_Well Construction - GW1_20220817

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS 1RWATER ZONES
` {
FROM 'I'O DESCRIPTION
ft.
Well Conti-actor Name ft. '
4519-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING'(far multi-case'VHS)OR LINER(if a. Gcable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 183 ft. 6 v8 ! #21 PVC
Company Name Q 16.INNER CASING OR TUBING(geothermal closed-loop)
2021-00306 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Countjt State. Variance,lctjection,etc.)
ft. ft• in.
3.Well Use(check well use): 1Z SCREEN
Water Supply Well: FROM TO DIAMETER, SLOTSIZ.E THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothenmal(Heating/Coolng Supply) El Residential Water SuPPIY(single) ft. tt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Cl Irrigation 0 ft' 20 ft. Bentonite Pumped
Non-Water Supply Well:
rt. rt.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Tcst ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gnin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 C° 83 ft OVER BURDEN
7-6-2022 83 ft 305 ft GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Kurt Busse
Facility/Owner Name Facility ID#(if applicable) ft. ft. ' r V r,
63 Fairview Point Drive Fairview, NC 28730
Physical Address,City,and Zip y
21.REMARKS 77, —
Buncombe 060568849500000
Countv Parcel Identification No.(PIN) �litx
5b,Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(il'well field,one lat/long is sufficient)
N w 7-12-2022
Signature cil`Cert-MA Well Contractor Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary Br signing this form,1 hereby certJv 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 ZNo cony ofthir record has been provided a,the well owner.
ll'thi.s Iva repair,{ill out known well construction iglornnalion and erplain the nature ofthe
repair under#21 remarks section or on the back o/'this,/ornn. 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: construction details. You may also attach additional pages if necessary.
For rradtiple injection or non-water supph•wells ONLY with the same construction,you can
Submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For muhiple wells list all depths if diferent(example-3 tJ200'and 2 a)100') Construction to the following:
10.Static water level below top of casing: LO (ft.) Division of Water Resources,Information Processing Unit,
If wirer 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 m 20 Method of test: RIG 24c.For Water Supply&Injection IWells:
(gP ) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 30 well construction to the county hea'Ith department of the county where
constructed. {€
Fonal G W-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013