GW1-2023-00668_Well Construction - GW1_20230105

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This Ingo can be used for single or multiple wells
1.Well Contractor information:
GARRETT CLYDE BANKS 14.WATER ZONES
FROM 'r0 DESCRIPTION
ft.
Well Contractor Name ft. i
4519-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(far multi-cased.avells)OR LINER(if a licable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 68 ft 6 1/4 #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed400
2022-00301 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. rt. in•
List all applicable urll permits(i.e.County,State.Pariance,h jection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER. SLOT SIZE THICKNESS MATF.RIAI,
ft. ft. in.
❑Agricultural ❑Municipal/Pub I is
❑Geothermal(Heating/Cooling Supply) El Residential Water SuPP1Y(single) ft. ft. in•'
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irieution 0 ft. 20 rt. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑klonitoring ❑Recovery
Injection Well:
❑Aquiler Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stonmwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG.(attach additional sheets if necessar
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rc. 68 rt. OVER BURDEN
10-17-2022 68 ft• 805 ft- GRANITE
4.Date Well(s)Completed: Well ID#
rt. rt.
5a.Well Location: ft. ft.
Samuel & Galina Carrillo ft ft r• �'
Facility/Owner Name Facility ID#(ifapplicable) ft. rt.
15 Ted Linn Drive Fairview, NC 28730
rt. rt.
Physical Address,City,and Zip 21.REMARKS r. - �• r+.�, n t L t
Buncombe 969621698300000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwcll field,one fat/long is sufficient)
N Nr7�1 r irjv3 12-19-2022
A YJ J
Signature oCCer-0td Well Contractor Date
6.Is(are)the well(s): Z Permanent or ❑Temporary At,signing this form,I hereby certify that the well(s)was(here)constructed in accordance
with 15A NCAC 02C.010(l or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EJNo copy gflhis record has been provided to the well owner.
/!'this is it repair,Jill out known well construction in/brmation and taplain the nature of the
repair under 921 rentarks section or on the back ol'this fora• 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 ifnecessary.
For nutbiple injection or non-water.ntpph•ivells ONLY with the sane construction,you can
Submit one'1brnt. SUBMITTAL INSTUCTIONS
9.•Total well depth below land surface• 805 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nutbiple nrel/s list all depths{'1'di(jerent(example-3 a 200'and 2 cd100') construction to the following:
10.Static water level below top of casing: 140 (ft) Division of Water Resources,Information Processing Unit,
If/wafer level is ahove 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 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
1
13a.Yield(gym) 1/2 Method of test: RIG
24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
131).Disinfection type: PILLS Amount: 35 well construction to the county hiallh department of the county where
constructed.
Foray t i W-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013