GW1-2022-10216_Well Construction - GW1_20221111

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
14 WATER ZONES l l
GARRETT CLYDE BANKS FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft.
VC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER ifa" Gcahle
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 65 ft.
6 1/4 in. 421 PVC
Company Name 16,INNER CASING OR TUBING(geothermal closed-loop)
EH24159 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Couno,,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. ft. in.
❑Agricultural ❑Municipal/Public
ft. f. in.
❑Geotheral(Heating/Cooling Supply) ElResidential Water SuPPIY(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑)rrieation 0 ft' 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. rt.
❑Monitoring ❑Recovery
lnjcction Well: ft. rt.
❑Aquifer Recharge ❑Groundwater Remediation -19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Esperinmental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grgin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rt. 5 tt. OVER BURDEN
10-28-2022 65 ft 325 ft GRANITE
4.Date Well(s)Completed: Well TD# ft. tt. ON
5a.Well Location: ft. tt.
Angela Kent/Anthony Bowen fc. NOVrt. 1 1
2022
Facility/Owner Name Facility ID#(if applicable) ft ft
Melvin Hill Road Columbus, NC 28722 ft. ft. 1
r
Physical Address,City,and Zip 21.REMARKS
Polk P126-16
Countv Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(il',vell field.one tat/long is sufficient)
11-7-2022
N W
Signature ofCertr Well Contractor Date
6.Is(are)the well(s): 2 Permanent or ❑Temporary Br 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
7.1F this a repair to an existing well: ❑Yes or ElNo copy gf1his record has been provided to the well owner.
11'1his is a repair,fill out known well construction injbrmation and e.rplain 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.
Fur nurlriple injection or non-water supply wells ONLY with the saute construction,you can
suhmit one jnrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 325 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Fur multple wells list all depths rfdgj&ent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
/bwater 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
m 13a.Yield
(gP ) 5 Method of test: RIG 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. I
Form Gw-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013