GW1-2022-02924_Well Construction - GW1_20220228

ft"V'ED
WELL CONSTRUCTION RECORD For Internal Use 0NLY: FEB 2 8 20?2
This form can be used for single or multiple wells
1.Well Contractor Information: a
GARRETT CLYDE BANKS F4=wATFRzoNES
FROM 'r0 DESCRIPTION
Well Contractor Name ft. ft.
4519-A
NC Well Contractor Certification Number �1S.OUTERCASfNCs.for mulh cased iYetls'OR NER_fia'_licable s,
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 it. 35 rt. 6 1/8 '" #21 PVC
Company Name
16.'INN ER CASING ORTUBING""euthermat closed ISo
359701 FROM TO DIAMETER THICKNESS l 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.S4REEN ,,aa,• � .... ..
Water Supply Well•• FROM TO DIAMETER': SLOT SIZE THICKNESS MATERIAL
in
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ft. ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) ft ;GROBT4
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well: ft. R.
❑Aquifer Recharge ❑Groundwater Remediation `19.,SAND/GRAVEL'=PACK,if a licab7e._ •-
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
f[. ft.
❑Experimental Technology ❑Subsidence Control
20.DRiLI ING LOG attach additional sheets if uecess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/mck type,gnin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 35 rt. OVER BURDEN
12-31-2021 35 ft 205 ft GRANITE
4.Date Well(s)Completed: Well ID#
tt. ft.
5a.Well Location:
Cody James Heatherly ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
310 Harley Springs Road ft.
Physical Address,City,and Zip
Madison 9860-57-4746
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one]at/long is sufficient) 0
12
N 12-31-2021
Signature of cent Well Contractor Date
6.Is(are)the well(s): ❑✓Permanent or ❑Temporary By signing this form,I hereby certifv that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo cony of this record has been provided to the well owner.
Ifthis 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
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 oneform. 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 ifdierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 25 (ft.) 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 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 10 Method oftest: RIG 24c.For Water Supply&Injection Wells:
(gp ) 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: 30
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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