GW1-2021-03777_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
Garr eft Banks FROM
WATER ZONES"
FROM TO DESCRIPTION
Well Contractor Name ft, I ft.
4519-A ft. ft.
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NC Well Contractor Certification Number 15.OUTER CASING'for multi-cased wells OR LINER if a `licable
FROM TO DIAMETER THICKNESS I MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 134 ft 6.25 #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
359992 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): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
ft. ft. in•
❑Geothermal(Heating/Cooling Supply) 17IResidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
El Irrigation 0 fr. 20 ft- Bentonite Pumped
Nun-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHODft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG`attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soillrock type,fimin sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fr 134 ft. OVER BURDEN
7-7-2021 134 it 565 it GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
Sa.Well Location: ft. ft. c
BRIAN RAMSEY
fr. ft.
Facility/Owner Name Facility ID#(ifapplicable) is
ft. ft.
1101 CALIFORNIA CREEK ROAD MARS HILL, NC 28754 ft. ft. � 7 l . +r.'�j(1
Phvsical Address,City,and Zip 21.-REMARKS yCt1<
MADISON 9757-74-9015 � o `" ';�9.�c:•
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(ifwell field,one lat/long is sufficient)
N W .�Qsu ern �owtiJ e,� 7-15-2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the weil(s)was(sere)constructed in accordance
with I5A NCAC 02C.0100 or 15A NCAC'02C.0200 Well Construction Slandards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy ofthis record has been provided to the we//owner.
I/'this is a repair,Jill oul known well construction information and explain the nature of the
repair under 21 remarks.section or on the back ofihis farm. 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: 1 construction details. You may also attach additional pages if necessary.
hhr multiple injection or non-water supply wells ONLY with the same construction,you can
.suhtno one Corm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 565 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
kor multiple we/l.s list all depths i/di/jerent(example-3 rt 200'and 2 t@i 100') construction t0 the following:
10.Static water level below top of casing: 50 (ft.) Division of Water Resources,Information Processing Unit,
(f nraer level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b. For Infection Wells ONLY: Itn 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 we5
12.Well construction method: construction to the following.
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources, 'nderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield m 15 Method of test: RIG 24c.For Water Supply&Injection Wells:
(gp ) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 35 well construction to the county health department of the county where
constructed. I,
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Form G W-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013