GW1-2022-09524_Well Construction - GW1_20221017

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used For single or multiple wells
I
1.Well Contractor Information:
GARRETT CLYDE BANKS F4.WATER.110
RO\I 1'O DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(far multi-cased wells)OR LINER(if a ficable .
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 fc. 101 it 6 1/8 i #21 1 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-too
MCM-309W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. I in.
List all applicable nrll permits(i.e.Count),,State. Variance,hyeetion,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZF THICKNESS MATERIAL
ft. ft.❑Agricultural ❑Municipal/Public in.
❑Geothemlal(Heating/Cooling Supply) El Residential Water Supply(single) ft. ft. in.
❑itI(ILIstrial/Commercial ❑Residential Water Supply(shared) 18.GROUT -
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft. 20 ft• Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑ FROM TO MATERIAL EMPLACEMENT METHOD
Salinity Barrier ft. tt.
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessar
❑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 101 ft. OVER BURDEN
9-19-2022 101 ft 425 ft GRANITE
4.Date Well(s)Completed: Well ID#
ft. it.
5a.Well Location:
Jeremy Chambers
Facility/Owner Name Facility iD#(ifapplicable)
tt. tt.
Pressley Road Canton, NC 28716 OCT -
Plhvsical Address,City,and Zip 21.REMARKS
Haywood 8566-25-6779 7;,�,
County Parcel Identification No.(PIN)
nb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(il'well field,one tat/long is sufficient) -A
N w
Signat 9-26-2022
ure of Cerit Well Contractor Dale
6.Is(are)the well(s): OPermanent or ❑Temporary Br signing this fortn,I herebv certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0h00 or 15.4 NCAC 02C.0200 lVell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of 1his record has been provided to the well owner.
/l this•is a repair,fill not known well construction injormalion and explain the:nature oJ7he
repair under#21 remarks section or of the back o/'thisform, 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 ifnecessary.
For multiple injection or non-Crater supple wells ONLY with the sante construction,you can
submit onefinn. SUBMITTAL INSTUCTIONS
9.'fotal well depth below land surface:425 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nuthiple n•ells list all depths ffdiftrent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
Ijtraler level is above erasing,use'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY:i 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(gpm) 3 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 35 well construction to the county health department of the county where
constructed.
Form UW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013