GW1-2021-07777_Well Construction - GW1_20210809

WELL CON.STRUCT'ION RECORD For Intemal use ONLY:
This form can be ri'sed:for single or multiple wells
1.Well Contractor Information:
GARRETT CLYD'E BANKS 1R.WATER ZONES ;
FROM TO 1.DESCRIPTION'
fit.
Well Contractor Name �• ft. '
4519-A
NC Well Contractor Certification Number Is•,0UTER CAMNG or multi-cased welts)ORLINER, fife 7icable
• ' FROM TO DIAMETER, THICKNESS .MATERIAL
CLYDE SAWYERS & SON WELL&;PUMP INC +1 fl, 28 fL 6.25 ; #21 PVC
Company Name OR'L
'. :l'Ci,,JNNERCAS_ ZRIW epthe rmal�osc loo''_ s�,.......R
336387 FROM TO DIAMETER THICKNESS' MATERIAL
2,Weli Construction Permit#: ft. tt. ' in.
List ail applicable'well permits'Ae.County,State, Variance,Infection;etc.)
3.Well Use(check well use):
17.-SCREEl1
Water Supply Well: FROM TO DIAMETER. SLOT SIZE THICKNESS MATERIAL
❑Agricultural :❑Municipal/Public ft. ft. in
❑Geothermal(Heating/Cooling Supply) EJResidential Water Supply(single) A. fit. in.
❑Industrial/Commercial OResidentia[Water Supply(shared) f$•GROII ..
FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
❑irri ation. 0 ft' 20 ft-, Bentonite Pumped
Non-Water Supply.Well:
fit. fit.
❑Monitoring ❑Recovery ,
Injection Well:.,
❑Aquifer-Recharge ❑Groundwater Remediation ' 9,.SANMIkA,ELPAC•'Kifa ,'cable
• '' FROM TO _ MATERIAL. EMPLACEMENT METHOD
❑Aquifer Storage and-Recovery , El Salinity Barrier fit. fit.
❑Aquifer Test ❑Stormwater Drainage
fit. fit ,
❑Experimental Technology, '❑Subsidence Control
26.DRILLING LOG°attaeti additional sheets'if necesa F
❑Geothermal(Closed.L Lop) :OTracer - E28f�-,
TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) 8 n. OVER BURDEN
06/16/2021 405 ft•' GRANITE
4.Date Well(s)Completed; Well ID# tt.
5a.Well Location:
9>
Jeffrey B Warren ft. ft:
Facility/Owner Name 1 Faailtty lbt(if applicable) 0
TBD N.C. 251 HVVY ft• fL
•U��it
Physical•Address,City,and Zip
Madison 9715-79-7280 '. ,.z>aREARcs�_ � ��Ill.a•�` °;
County Parcel Identification No.(PIN) i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: �22.Certiflcatlofi.
(if well field,one lat/long is sufficient)
N 06/17/2021
Signature ofCern Well Contractor Date
6.Is(are)the well(s): RPermanent or ❑Temporary B,signing this form,I hereby certifv that the well(s)was(were)constructed inaccordance
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 ElNo copy of this record has been provided to'lhe well owner.
If this is d repair,fill out known well construction'information End 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
8.Number of wells constructed: construction details. You may also attach'additional pages if necessary.
For multiple injection or non=water supp(v wells ONLY with the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:405 (fit.) 24a. For All Wells: Submit this form within 30 days of completion,of well
For multiple wells list all depths ifdifferetu(example-3@200'and 2@100') construct' n to the following:
10.Static water level below top of casing: 30 Division of Water Resources,Information Processing Unit,
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 Fopy ofithis formWithin 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
f8 RIG 24c.For Water Supply&Injection Wells:j
M.Yield(gpm) Method otest:
Also.submit one copy of this form(within'30 days of completion of
PILLS" well construction to the county health department of the.county where
13b.Disinfection type: � � Amount: 20 �
constructed.
Forth GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013