GW1-2021-06554_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14'WATERZONES
GARRETT CLYDE BANKS n:: . a...,. .. ._
FROM '1'O DFSCRIPTION Well Contractor Name ft. ft.
4519—A it. ft.
NC Well Contractor Certification Number '0J5.OUTER CASING for multi-cased wens OR LINER it a'" licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 59 ft- 6.25 ; #21 PVC
Company Name :16 INNER CASING OR TUBING 'eothermal dosed-too ",_,
N RH-261 W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State, Variance,11 jection,etc.)
ft. ft. in.
3.Well Use(check well use): r �=
17.SCREEN'. rt 1�`-:'_.: .:;.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT ?
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVELPACK if applicabI6,
❑ FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
70 DRILLING LOG attach additional sheets if oecess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 59 ft. OVER BURDEN
09/15/2021 59 rt• 345 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Jeremy & Erika Jensen tt. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
Scooters Trail
ft. ft.
Physical Address,City,and Zip
Zt:REMARKS !'::
Haywood 8712-91-8653 informatton `roc
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one IaVlong is sufficient)
09/15/2021 N �
Signature of Certr Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certifv that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No cope of this 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 of this form. 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: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,von can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 345 -(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iftli ferent(example-3@100'and 1@1001 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 Center,Raleigh,NC 27699-1617
I I.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 m 6 Method of test: RI G 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: 20 well construction to the county Health department of the countywhere
constructed.
Forst GW-1 North Carolina Department of Environment and Natural Resources—Division of Water;Resources Revised August 2013