GW1-2022-10136_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
GARRETT CLYDE BANKS FR WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
4519-A
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased'wells)OR LINER(if;ap Gcable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 137 it 6 1/4 '" #21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed400
2022-00004 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: tt. tt. in.
List all applicable nrll permits(i.e.Counn+,.State.Variance,Injection,etc.
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZF. THICKNESS MATERIAL
ft. ft. in.
❑A_ricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water SuPP1Y(single) f. f. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.'GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 "' 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: it. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(ifapplicable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiltrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft- 137 ft. OVER BURDEN
4-29-2022 137 It- 305 ft- GRANITE
4.Date Well(s)Completed: Well iD#
ft. it.
5a.Well Location:
Viktor Malanka ft. it,
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
99 Timber Ridge Leicester, NC 28748
Physical Address,City,and Zip "2L REMARKS
Buncombe 8792938585 oMra�oc
ConntV Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification,
lifwell Held,one lot/long is sufficient) i
11-2-2022 N W
Signature of Cenn Well Contractor Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary Br 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
7.Is this a repair to an existing well: ❑Yes or EINo copy q/lhis record has been provided to the well owner.
it rhic is a repair.Jill out known well construction information and erplain the nature ofthe
repair under#21 remarks section or on the back of this,(orm. 23.Site diagram or additional well ldetails:
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 ifnecessary.
For multiple injection or nun-wotcr.rupply wells ONLY with the same construction,you can
suhmit one(ornn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 305 (ft.) 24a. For All Wells: Submit this'form within 30 days of completion of well
For nrtdriplc N'elLr list all depths il'di(Jerent(example-3 u,200'and 2 cil100') construction to the following:
10.Static water level below top of casing:
40 Division of Water Resources,Information Processing Unit,
(ft.)
I!oath 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(gym) V
G 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 heath department of the county where
constructed.
Fornr GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013