GW1-2022-07793_Well Construction - GW1_20220822

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
rt. rt.
4519-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a
FROM TO DIAMETER THICKNESS Geable MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 fl, 72 ft- 6 1/8 #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-too
W21-0654 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. I in.
List all applicable well permits(i.e.Count),,State. Variance,/ejection,etc.) ft. ft.
in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SI7,E THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ElResidential Water SuPPIY(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ff. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. R.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK ifa licablc
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑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' 72 tt OVER BURDEN
6-14-2022 72 rt. 585
4.Date Well(s)Completed: Well ID#
ft. ft. iz%_0 a_s
5a.Well Location: tt. ft. 9
CMH Homes Robinson ft. rt. " _ - -
Facility/OwncrName Facility ID#(ifapplicable) ft ft Ift#C,t 1 Es EC7 Pracz<r=3 n4'
159 Hidden View Loop Marion, NC 28752
Physical Address,City,and Zip 21.REMARKS
Mcdowell 079100077915
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)
N N, 6-23-2022
Signature of Certt Well Contractor. WqJLL/ Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,I hereby certijy'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 ElNo cops'ofthis record has been provided to the well owner.
//'this is a repair,fill out known well construction inlbrmation and(crplain the nature of the
repair larder#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 multiple injection or non-water.supply wells ONLY with the saute construction,you can
submit nnefnrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 585 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdilferent(example-3 a 200'and 2 a 100') construction to the following:
10.Static water level below top of casing: 70 Division of Water Resources,Information Processing Unit,
if water level is above easing,use"+" 1617 Mail Service iCenter,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 ServiceiCenter,Raleigh,NC 27699-1636
13a.Yield m 1.5 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: 35 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
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