GW1-2021-03698_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS F4.wATER. NEs.-v: . ..
FRObt TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number t5:OUTER CASING,foie moth eased we119 OR LINER if
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 103 ft 6.25 1" #21 PVC
Company Name
;.16.INNER CASING OR TUBING eo'thermal:elosed lob >F.. "" `
MCM-217W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use check well use): CRIE
Water Supply Well: FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) IIResidential Water Supply(single) t"
❑Industrial/Commercial ❑Residential Water Supply(shared) ,IS•GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
tt. tt.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation FROMD/GRA li'�ACK,if a 'l cable-
MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control
20.:DRILI�ING°IOG"attach-additiona"t'sheets'if recess � ,`�..,� -��
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft 103 ft OVER BURDEN
07/21/2021 103 ft 205 ft GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location:
John Holland
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
Worley Cove Rd, Canton AU ,
Physical Address,City,and Zip
Haywood 8678-16-9834 Irdarl^at<clii � �
t
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one latllong is sufficient)
N W 6 07/21/2021
Signature of cerlr Well Contractor Dale
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,1 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 FINo 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#21 remarks section or on the back ofthis 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: construction details. You may also{attach 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• 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifeliferent(example-3@200'and 2@100') construction t0 the following:
30 Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: (ft.)
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
(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) 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: Amount: 2�
PILLS well construction to the county health department of the county where
constructed. �
Forst GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013