GW1-2021-00137_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS 1RWATERZONES
FROM '1'O DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER(if a tieable
RIAL
FROM TO DIAMETER THICKNESS MATE
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft' 73 ft- 6 1/8 #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2020-00519 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. rt. in.
List all applicable well permits(i.e.Count),.State. Variance,ltjeetion,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MA'1't:RIAL
ft. ft. in•
❑Aericultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water SuPP1Y(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
El Irrigation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. rt.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets flnecessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil-- ck type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 73 ft• OVER BURDEN
10-13-2021 73 ft• 165 ft• GRANITE
4.Date Well(s)Completed: Well ID#
ft. rt.
5a.Well Location: fL it.
ROSEANNE BOSCARELLO ft. ft.
Facility/Owner Name Facility ID#(if applicable)
59 ROSIES STARLIT TRAIL LEICESTER, NC 28748
rt. rt.
Physical Address,City,and Zip 21.REMARKS
BUNCOMBE 97031031880000 -
Countv Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one hat/long is sufficient)
A 1 11-22-2021 /
N W
Signature ofCerti Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporal•)• Br signing this form, I hereby certfv 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 KNo copy ql this record has been provided to the well owner.
//'this is a repair.Jill out known we!/construction in%arna(ion and explain the nature of the
repair under#21 remarks section or on the back of this.Jorm. 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 iniection or nonovater,supply we//s ONLY with the saute construction..i ou can
submit one./'arm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 165 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple av/ls list all depths ih diljerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 5 (ft.) Division of Water Resources,Information Processing Unit,
Il eater level is above casing.rtse"+" 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
13a.Yield
(gpm) Method of 100 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: 20 well construction to the county hiealth department of the county where
constructed.
Fur+a+GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013