GW1-2021-00150_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 FRONT T
RON TO DESCRTP7TON
Well Contractor Name
4519-A
NC Well Contractor Certification Number 0101
for I l`f
FROM TO DIAMETER THICKNESS MATERIAL.
CLYDE SAWYERS & SON WELL & PUMP INC +1 rl, 26 ft- 6.25 in. #21 PVC
Company Name :, .E Rf1II#T1) 1,,. . .. > h. 1..
2021-00206 FROM DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: in.
List all applicable well permits(i.e.Counn•,State,Variance,Injection,ere.) Ct. ft. in.
3.Well Use(check well use): LE .
Water Supply Well: FROM TO DIAMETER SLUT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) in.:
❑lndustrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑h'ri ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 1a'1tASE it
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. ft.TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control Mmm
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardness soatr k type. rain size,etc.
❑Geothermal (Heating/Cooling Return ❑Otber(explain under#21 Remarks) 0 ft' 6 ft OVER BURDEN
11-03-2021 26 ft 265 ft GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Svetlana Maystruk
Facility/Owner Name Facility ID#(ifapplicable) 2021
rt. rt.
20 govenor's view rd Asheville, NC ft.
_.r
Physical Address,City,and Zip ,21m,mwik
BUNCOMBE 96585482050000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
(if well field,one tattlong is sufficient) 082.51212 N 35.578934 W 12-06-21
Signature of Certi Well Coutractor Dale
6.is(are)the well(s): OPermanent or ❑Temporary By g s•1 in this form,/herehti•certi�y that the weIIO
was(were)constructed in accordance
with 15A NCAC 02C.0100 ar 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 5No copy of this record has been provided to the well owner.
If this is a rrpair,fill out knuun well construction information and explain the nature of the
repair under#21 remarks'section or on the back of this>orm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may al4attach 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: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ii(diff rent(example-3(d�00'and 2(a-100') construction to the following:
10.Static water level below top of casing: 20 (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 Iniection 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 Method of test- RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 20 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013