GW1-2022-07636_Well Construction - GW1_20220817

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
GARRETT CLYDE BANKSzo
FROM TO ._�DESCR.f u._ ..__. .. �.:._... .. � .. ..,.... .._.,
PTTOV
Well Contractor Name ft. ft.
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4519-A ft.
NC Well Contractor Certification Number 15:OUTER CASING for:airutd easedswetls`.OR:LI]YER. fa'lieable
FROM TO DIAMETER T'ka'AR.SS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 1100 ft- 61/8 in #21 1 PVC
Company Name 16.INN£l2.CA'$ING QR TUBING; eutheTMA closetl too z ..:.
2021-00527 FROM DIAMETER! 1'NICKNF;SS MA"1'ERI.AI.
2.Well Construction Permit#: ft. ft,
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.!
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. rn•'
❑Industrial/Commercial ❑Residential Water Supply(shared) 18"GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOU.W
❑hri ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediatimr 19:`SAND/GRAVEG'1'A4CI£ if a" •i3ible .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20:DRILLING LOG.itfaa_ti addiha aI sheetsifiiecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/ ck tv e.gmin size,etc.)
❑Geothermal(HeatinglCooling Return[) ❑Other(explain under#21 Remarks) 0 it, 100 tt• OVER BURDEN
07-08-22 100 rt• 565 ft GRANITE
4.Date Well(s)Completed: Well ft. ft.
59.Well Location: n -
CMH Homes
ft. ft.
Facility/Owner Name Facility ID#(if applicable)
1073 Sharon Ridge Rd ft. ft. Ifw`�f ;ati�� �, � wf 0 Unh
Physical Address,City,and Zip ,31,RGe144RKS.r
�..
BUNCOMBE 968528195500000 �!
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 07-15-2022
Signature of Cedr Well Contractor Date
6.is(are)the well(s): 2Permanent or ❑Temporary
By signing this form,!hereby cerh(}'that:the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo ropy of this record has been provided to the well owner.
I(this is a repair.fill out knuun well construction information and explain the nature of the
repair under#21 remarkv section or on the back d f this/orm. 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 ifnecessary.
For multiple injection or non-water.supply wells ONLY will[are same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 565 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifJerent(example-3(V00'and 2(a,'100') construction to the following:
10.Static water level below top of casing:45 (ft.) Division of Water Resouirces,Information Processing Unit,
7fwaier level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection 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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 1.5 Method of test: RIG Also submit one copy of this ['orm l within 30 days of completion of
13b.Disinfection type: PILLS Amount.- 19 well construction to the county health department of the county where
constructed.
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Forte GW-I North Carolina Department of Environment and Natural Resources—Division of Water Re ources Revised August 2013
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