GW1-2022-05284_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:
GARRETT CLYDE BANKS F14.ROM ERzo Es.
. ..,
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A it. it.
NC Well Contractor Certification Number I5.OVTERCASING(for'multi-cased wefts)'OR LAVER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 I'L 71 it. 6 118 in. #21 PVC
Company Name
.1CJNNER'CASING,ORTUBING eothermalAosed-loop)
21100121331 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): I7 gCEly„
Water Supply Well: FROM TO DIAMETER _ SLOT SIZE THICKNESS MATERIAL
ft. ft.❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Coolin Supply) BResidential Water SuPP1Y(single) ft. ft. in.
�•
❑Industrial/Commercial ❑Residential Water Supply(shared) :18.GROUT ...
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/G L PACK if a`licable. .
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft. '
[]Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets ifluecess"
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiUrock type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fr' 71 rr• OVER BURDEN
05-16-2022 71 fr• 365 rr• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
N Carolina Properties
Facility/Owner Name Facility ID#(if applicable) 421
ft. ft.
493 Patterson Rd. ,, s::,; {; „
,..;
Physical Address,City,and Zip 21:REh1ARICS w �t {` 1 i 7
Henderson part of 9548014379
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) -A
VA V1 N W 05-18-2022
Sig nature of Ceru Well Contractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)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 well: ❑Yes or ENo copy 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 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: 1 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 one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 365 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@I00) 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 3 Method of test: RIG 24c.For Water Supply&Injection Wells:
(gP ) 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.
Forth GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013