GW1-2022-03010_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
GARRETT CLYDE BANKS 14.
FROM WATER ro
FROM 'I'NES DESCRIPTION
Well Contractor Name
4519-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a 6eable
RIAL MATE
FROM TO DIAMETER THICKNESS
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 50 ft- 6 1/8 '" #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
21-247 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable sell permits(i.e.County,State, Variance,Infection,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
❑Geothemnal(Heating/Cooling Supply) OResidential Water SuPPIY(single) ft. f. in
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
El Irrigation 0 ft' 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothennal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type.gnin size,etc.
❑Geothennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 50 ft. OVER BURDEN
2-8-2022 50 fL 125 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft.
Baylee Bagwell it. ft. 9
Facility/Owner Name Facility ID#(if applicable)
e. rt.
4243 East Fork Road Brevard, NC 28712 ft.
Physical Address,City,and Zip 21.REMARKS t.
Transylvania 8581-65-9636-000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field.one tat/long is sufficient)
a A 2-17-2022
N W
Signature of Certt Well Contractor Date
6.Is(are)the well(s): WPermanent or ❑Temporary Br signing this form,i hereby certify that the well(s)was(were)constructed in accordance
With 15A NCAC 02C.0100 or 15A NC'AC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy gf1his record has been provided to the well ox-ner.
11 rhi.s is a repair.fill out known well construction in./brmation and explain the nature of the
repdr under 921 remarks section or on the hack of this fora. 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.
For multiple iniectiun m non-water svpplr wells ONLY with the scone constnrztion,sou can
SUBMITTAL INSTUCTIONS
suhmit one,form. '
9.Total well depth below land surface: 125 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple hells list all depths if'different(example-3 a 200'atnd 2@100') construction to the following:
10.Static water level below top of casing:
20 Division of Water Resources,Information Processing Unit,
(ft.)
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(gpm) 30 Method of test: RIG 24c.For Water Supply&Injection Wells:
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 county where
constructed.
Foro3 GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013