GW1-2021-00145_Well Construction - GW1_20211213

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS d4.WATERzoNES FROM '1'O DESCRIPTION
Well Contractor Name ft. ft.
4519-A
NC Well Contractor Certification Number 15.0UTER CASING for multi-eased.weils OR LINER ira'`likable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 54 ft. 6.25 in. #21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed400 'r
2021-00041 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt. in.
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.❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) E lResidential Water Supply(single) ft,
ft. in.
❑Industrial/Commercial ❑ 18.GROUTResidential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a likable s
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwatcr Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING'IbG.attach additional sheets if recess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gnin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft' 54 tt' OVER BURDEN
12-02-2021 54 rt• 205 rt• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Petr Alekseyevich Malanka
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
Fletcher Martin Rd.
Physical Address,City,and Zip
BUNCOMBE 9722086792 21REMARKS'
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 12-03-2021
Signature of Cent Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary Br signing this form,1 hereby certify that the we/l(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 ElNo cony of this record has been provided to the well owner.
1f this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 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 same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing• 25 (ft.) Division of Water Resources,Information Processing Unit,
1f 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 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)
10 Methodoftest: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this foim within 30 days of completion of
13b.Disinfection type: PILLS Amount: 30 well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013