GW1-2022-09458_Well Construction - GW1_20221017

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This Corn[can be used for single or multiple wells
I.Well Contractor Information:
'GARRETT CLYDE BANKS FROM1RWATERZONES
O\[ "r0 DESCRIPTION
Well Contractor Name ft. ft.
4519-A
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a Gcable)
.FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 121 ft- 6 1/8 ' in. #21 1 PVC
Company Name 16.INNER CASING;OR TUBING eothermal closed-loop)
2021-00209 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Count),,State. I"ariance,hjection,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.
❑Agri cu Rural ❑Municipal/Pub I is
❑Geothermal(Heating/Cooling Supply) IResidential Water Supply(sin(single) Ct. ft. in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lni ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVELPACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 121 ft. OVER BURDEN
8-1-2022 121 ft, 485 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Bradley Jeffey
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Summit Road Swannanoa, NC 28778 ft.
Physical Address,City,and Zip 21.REMARKS
Buncombe 060838184100000 V,!Q(7"OG n,
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lot/long is sufficient)
r�T— -A 9-22-2022
N W _
Signature ofCertn Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby certiijv 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 FlNo copy gfthis record has been provided to the well owner.
Il'this is a repair,Jill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back gl'thisJorm. 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 or non-water supply wells ONLY with the scone construction,you can
ubmit one firm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 485 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nuthiple wells list all depths rfdiftrent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing• 60 (ft.) Division of Water Resources,Information Processing Unit,
!/'water 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 to
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) 3 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
PILLS
13b.Disinfection type: Amount: 35 well construction to the county health department of the county where
i
constructed.
i
Form CiW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013