GW1-2022-02849_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
GARRETT CLYDE BANKS FRRO�IOM R.ZONES ': -
TO DESCRIPTION
ft. ft. t ratiur tu:ui ,{�
Well Contractor Name i
4519-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-easediwells)OR LINER(if a lica' ble)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 65 e• 6 1/8 421 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2021-00636 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt. in.
List all applicable Hell 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 MATERIAI.
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ©Residential Water SuPP)Y(single) ft. tt. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 tc. 20 rt• Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary),
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION(color,hardness,soil rock type,grain size,etc.)
❑Geothenmal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rt 65 rt OVER BURDEN
12-3-2021 65 fc 660 ft GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Igor Korolchuk
Facility/Owner Name Facility ID#(ifapplicable)
68 Squires Lane Candler, NC 28715
Phvsical Address,City,and Zip 21 REMARKS
BUNCOMBE 9608643153
Countv Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification-
(if well field,one tat/long is sufficient)
12-15-2021
N W
Signature of Certr Well Contractor Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form, I hereby certify that the well(s)was(were)constructed in accordance
with I SA NCAC 02C.0I00 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONO copy ofthis record has been provided to the well owner.
if thi.v i.v a repair,fill out known well construction information and c�vplain the nature of the
repair under#2I 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,van can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 660 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi(jerent(example-3 a 200'and 2@/00') construction to the following:
10.Static water level below top of casing: Dry (ft) Division of Water Resources,Information Processing Unit,
If 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) O Method of 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: 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