GW1-2022-05257_Well Construction - GW1_20220526

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
:.
GARRETT CLYDE BANKS FROM TO DESCRIPTION
Well Connector Name
4519-A
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if;a licable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 75 rt. 6 1/8 in. 1 421 PVC
Company Namc 16.INNER CASING OR TUBING(geothermal closed400'
JMQ-203W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in•
List all applicable well permits(i.e.Counb,,State. Variance,Injection,etc.) ft ft. in.
3.Well Use(check well use): 17,SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. fL in:
❑Agricultural ❑Municipal/Public
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water SuPPIY(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
El Irrigation 0 fc. 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 EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
30.DRILLING LOG(attach addifion'alsheets-if necessar t
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 it' 75 ft• OVER BURDEN
4-14-2022 75 ft- 145 ft- GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
Noah & Jordan Ruff ft. rt
.
Facility/Owner Name Facility ID#(ifapplicable) ft. . ft.
1229 Silver Cove Road Clyde, NC 28721 ft. rt. lV1H
Phvsical Address,City,and Zip 21.REMARKS
Haywood 8730-47-2648
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 WL�o04-18-2022
Signature ofCertirlK Well Contractor Date
6.Is(are)the well(s): OPermanent or []Temporary Br signing this form,I hereby certify that the tvell(s)was(were)constructed in accordance
,vith 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 the well owner.
I/'this is it repair,fill out known well construction information and explain the nature ofthe
repair under#21 remarks section or on the back o/'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: 1 construction details. You may also attach additional pages if necessary.
For rmdtiple igieetion at,non-water supph•wells ONLY with the scone construction,you can
srrbnril onto Jnnn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 145 _(ft.) 24a. For Au Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdgl&rent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 20 (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 Injection 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) Method of test: RIG
10 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.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013