GW1-2021-03937_Well Construction - GW1_20211111

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WELL CONSTRUCTION RECORD (GW-1 )
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Form GW-1 Well Construction Electronic Form
North Carolina Department of Environmental Quality
Division of Water Resources
April 1,2021
Submission ID#
GW1-2021-03937
Are you submitting a printed form?* Yes
No
CONTACT INFORMATION
.......................................................................................................................
Contact Name* Email Address*
Gary Justice [e-mail]
Is this a revision to the form you have previously submitted?*
Yes No
WELL CONSTRUCTION INFORMATION
........................................................................................................................................................................................................................................................................................................................................................................................................................................................
1.Who is installing these wells?*
Owner Well Contractor
1.Well Contractor Information:
Certiticate# Cert Level First Name Last Name Company Name
2150 A GARY JUSTICE JUSTICE WELL DRILLING, INC.
2.Well Construction Permit#:
WI 100628
List all applicable well construction permits(i.e.Monitoring Wells,UIC,County,CCPCUA,etc.)
What type of well is this?* Injection Well Non-Water Supply Well
Water Supply Well (includes irrigation wells)
3.Water Supply Well* Geothermal (Heating/Cooling Supply) Industrial/Commercial
Irrigation Municipal/Public/Community
Residential Water Supply(single) Residential Water Supply(shared)
Wells> 100,000 GPD
4.Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
10/29/2021 (gallons per minute)"

5.Well Location
Facility/Owner Name*
Richard Alan Feld Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Buncombe 972172618700000
Physical Address* Street Address
23 Bee Balm Way
Address Line 2
City State/Province/Region
Asheville NC
Postal/Zip Code Country
28804 US
Latitude* 35.6541154000 Longitude*-82.6104193000
Decimal degrees Decimal degrees
..... ......... ......... ..... ......... ......... ......... ......... ..... .........
6.Is(are)the well(s):* Permanent Temporary
7.Is this a repair to an existing well:* Yes No
If 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.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a.Indicate TOTAL NUMBER of wells drilled: 1
9.Total well depth below land surface: (ft.)
205 9a.What is the depth of the casing from ground
surface?
For multiple wells list all depths if different
(example-3@200'and 2@100') in feet
11.Borehole diameter:
10.Static water level below top of casing: (ft.) 6.13
If water level is above casing,use"+" in inches
12.Well construction method:
Auger Air Rotary Cable Tool
Direct Push Mud Rotary Rotosonic
Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gpm) 13a.Method of test:
If applicable Air
13b. Disinfection type:* 13b.Amount:*
CHLORINE 8 OZ
......................
14.WATER BEARING/FRACTURE ZONES
From To Description

in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
0.00 205.00 12.25 3/4" plastic twister loop
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
in feet in feet in inches
18.GROUT
................... ...........................................
From To Material Emplacment Method&Amount
0.00 205.00 Easy Seal Trimmy line pumped
in feet in feet
19. SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
in feet in feet
20. DRILLING LOG
From To Description(color, hardness,soil/rock type,grain size,etc.)
0.00 80.00 soft rock and dirt
in feet in feet
80.00 205.00 granite
in feet in feet
21. Remarks
22.Site diagram or additional well details:
You may upload additional well construction information here.
pdf only
CERTIFICATION INFORMATION
* By signing this form, I hereby certify 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 copy of this record has been provided to the well owner.
23.Certification*
Signature of Certified Well Contractor
Submittal Date 11/11/2021