GW1-2022-09462_Well Construction - GW1_20221017

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.3tAIIR.ZANGS <
GARRETT CLYDE BANKS PRO TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number 15%:60TPk"l i151MCi,for i utd,caee+l:=tivelts OIE I t3iikil.lia tScahte`:
FROM TO DIAMETER 1 THICKNESS hrATERr.AL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 177 ft- 61/8 tin #21 PVC
Company Name 16,1}vivER CA [ 1G,pi{a UB11N0 SQifhei'iniaYsWsed
2021-00366 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. rt. ; in.
List all applicable moll permits(i.e.County,State,Variance,Injection,e(c.) ft ft. in
3.Well Use(check well use): f7z MEEK_ ; .�
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in•
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) E�IResidentlal Water Supply(single) in.,
❑IndustrialtCommercial ❑Residential Water Supply(shared) ."1...
FROM TO MATERIAL EMPLACEMENT METHOD f AMOUNT
❑TrTi ation 0 ec. 20 tc• Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft.
❑Aquifer Recharge ❑Groundwater Remediation
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
..20LtIttC,L1NL>1L(fG kttartiadditlot3LsLeett§3faieeessarv�-� `� .v.���•.�" F'.s'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soit(rockty a grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 77 fr OVER BURDEN
7-26-2022 77 ft 545 fr GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft. .'-" s s' jffi^i s
Paul Dascanio II ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft q
. ft. OCT ' 2
145 Vanderbilt Terr. �r
ft. rt. to;ir;�r.'sa�n u
;'f�.,��� ��;
Y Y P a...
Physical Address,City, Zi
Buncombe 9626461023 ;
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certitication:
(if well field,one IaUlong is sufficient)
N 8-25-2022
signature of C., Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary y fy (� (were)B signing Ihis urns,1 herehv cent that the well(s)was rver•e constructed in accordance
with 15A NCAC 02C.0100 nr 15A NCAC 02C.0200 11 ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 921 remarks section or on the back of lhisJorm. 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 also attach additional pages ifnecessary.
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: 54 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iitdi ferent(example-3(d200'and 2(a100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"+" 1617 Mail Service C I enter,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: constmction 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) 5 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 heal Ih department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013