GW1-2021-07438_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Garrett Banks 14.'WATER ZONES l
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number IS.:OUTER CASING"for multi-cased wells'OR:LIfYER if a"-livable
FROM TO DIAMETE THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 92 f`- 6.25 in. 1 '#21 1 PVC
Companv Name 16.INNER CASING OR TUBING(geothermal closed-loop)
3288222 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. fr. in.
List all applicable hell permits(i.e.CounN,State,Variance,Injection,etc.)
ft. fL in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(sin(single) ft. f. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft' 47 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional shfets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness sail/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 92 ft. OVER BURDEN
6-2-2021 92 fL 365 rt GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: R. ft.
PARAGON WOODWORKS ft. rt. t
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. ,
WALNUT COVE ROAD CAROLINA RIDGE LOT 31 MARSHILL,NC ft. ft. UG
Physical Address,City,and Zip 21.REMARKS n
MADISON 9757-92-0626
County Parcel Identification No.(PIN) 1
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one latllong is sufficient)
N W 6-18-2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary By signing this form,I hereby certify that the svell(s)was(were)constructed in accordance
with 15A NCAC 02C.0I00 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 91No copy of this record has been provided to the well owner.
/(this is a repair,fill out known well construction information and explain the nature of the
repair under.21 remark,'.section or on the back q/'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
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
hor multiple injection or non-water.supply wells ONLY with the same construction,you can
SUBMITTAL INSTLiCTIONS
suhntlt one farm.
9.Total well depth below land surface: 365 (ft.) 24a. For All Wells: Submit this form Within 30 days of completion of well
1,or nminple welds list all depths Ifdt#j,rem(example-3 c@i 200'and Z 100') construction to the following:
10.Static water level below top of casing: 80 (ft,) Division of Water Resources,Information Processing Unit,
U it level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I1.Borehole diameter: 6.25 (in.) 241b. 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.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) 6 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: 35 well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013