GW1-2022-03947_Well Construction - GW1_20220412

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS FRO WATER ZONES '
FROMTO DESCRIPTION
Well Contractor Name
4519-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 124 ft- 16 1/8 in. 1 #21 PVC
Company Name 16 INNER CA5ING,ORTUBINC "eothermal closed-lod
21100115349 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: tt. ft. in.
List all applicable well permits(i.e.County,State, Variance,h jection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT S17E THICKNESS MATERIAL
❑Agricultural OMunicipal/Public in.
❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT .
FROM TO- MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. tt.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19 SANDIGRAS?EL PACK if a licablc
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft, ft.
❑Aquifer Test OStormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
[]Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiltrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) []Other(explain under#21 Remarks) 0 ft' 24 ft' OVER BURDEN
03-15-2022 24 ft• 745 «• GRANITE
4.Date Well(s)Completed: Well iD#
ft. ft.
5a.Well Location:
Rebecca Owen
Facility/Owner Name Facility ID#(if applicable) ft. ft.
647 Folly Rd. ft. ft.
Physical Address,City,and Zip 21.REMARKS
Henderson 9537599541 UN
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
N NnAA 04-06-2022
Signare of Ceru Well Contractor tu Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing web: ❑Yes or [!JNo Cory of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or at 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: 745 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing• 25 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(gym)
2 Method of test: RIG 24c.For Water Supply&Injectiin Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 30 well construction to the county health department of the county where
constructed. I
Form GW-i North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013