GW1-2022-03908_Well Construction - GW1_20220412

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.
FRWATERZONES
FROM '1'O DESCRIPTION
Well Contractor Name
ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-eased lwells)ORLINER(ifa hcable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft, 174 r° 6 1/8 #211 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
WP21-152 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Counm.State. Variance,ltgection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATF.RIA I,
ft. fL in.
❑Agricultural ❑Municipal/Public
ft. ft. i";
❑Geothennal(Heating/Cooling Supply) EIResidential Water Supply(sm(single)❑Industrial/Commercial ❑Residential Water Supply(shared) 15.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
El Irrigation 0 fc. 20 rt. Bento6ite 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
❑Aquiter Storage and Recovery ❑Salinity Barrier
❑Aquifer Tcst ❑Stonnwatcr Drainage
II. ft.
❑Lxperimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additionalsheets if necessary)
❑Geothennal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiBrock type,grain size,etc.)
❑Geothennal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft- 174 ft. OVER BURDEN
3-11-2022 174 ft• 425 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Jessica Traylor f., ft. �'
Facility/Owner Name Facility ID#1(ifapplicable) ft. ft.
300 Ross Road Brevard, NC 28712
ft. ft.
Plivsical Address,City,and Zip 21.REMARKS
Transylvania 8564-77-2507-000
r: r
Countv Parcel Identification No.(PIN)
51).Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field.one lat/long is sufficient)
N w
3-25-2022
Signature ot'Certi Well Contractor Date
6.Is(are)the well(s): 2 Permanent or ❑Temporary Br signing this form, 1 hereby certyY that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.020(l Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo cope gfthis record has been provided to the well owner.
If lhi.s is a repair.fill out known well construction i ilbrmation and e.rplain the nature o/the
repair under 421 remarks section or on the hack of this 16 nt. 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 ifnecessary.
For multiple injection or non-water supply wells ONLY with the satne construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 425 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple we/h list all depths i/di fferent(example-3@200'and 2G100') Construction to the following:
10.Static water level below top of casing: 50 (ft) Division of Water Resources,Information Processing Unit,
If ualer 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
i
13a.Yield(gpm) Method of test: RIG
24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13h.Disinfection type. PILLS Amount: 35 well construction to the county health department of the county where
constructed. B
Fol m GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013