GW1-2023-00597_Well Construction - GW1_20230105

i
WELL CONSTRUCTION RECORD For Internal Use ONLY: I i
This form can be used for single or multiple wells Ilk
1.Well Contractor Information:
GARRETT CLYDE BANKS FRO TO
r
TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A
NC Vi'e1lContractorCertif�cationNumber t5;:fttiTt 8t ASWG,for.`trtutdS-casrdauetts OR-'f 13VkR ifs ltcabie<'
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 109 ft- 6 1/4 in. #21 PVC
Company Name 1b.:IIVl+1ER Cs1$(3YG.ORT:UBING sOfhet7naF;otosed tpo `:
W22-0304 FROM DIAMNIER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. in.
List all applicable Kell permits(i.e.County,State,Variance,Injection,etc.) ft. ft.
in.
3.Well Use(check well use): 1 L:SCRERl!L,.... zs
Water Supply Well: FROM TO DIAMETER SLOT SIZE THTCKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑MunicipaVPublic
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) tt [t m
1tI GR011T. .... �,. ... > y, .:: t
❑IndustriaUCommercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD AMOUNT
❑hri ation 0 et. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 29.:$AlYD7GRAVELPAGIC'd:a""'tirbie
FROM TO MATERIAL E51PLACEMF-NT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
.1 0.�=t ig I1G MG:, a iittaeliada1 abet i heets:if" essa. z-- ......... �
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type. rain size,etc.)
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 fL 109 f< OVER BURDEN
12-1-2022 109 ft• 205 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location:
Austin Myers
Facility/Owner Name Facility ID#(if applicable)
39 W. Holly Ridge, Old Fort ft. ft.
c.
Physical Address.City,and Zip 21,�REMARF5,
t
�._;
McDowell 064900863562
ulih
County Parcel Identification No.(PIN) [IMM 3OG
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifw•ell field,one lat/long is sufficient)
N W h_
12-2-2022
Sign tore of Cntr 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 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0300 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or FlNo copy of this record has been provided to the well owner.
If this is a repair,fill out knoww well construction information and explain the nature of the
repair under#21 remark,,section or on the back ofthLvJbrm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-water supply wells ONLY with the saute construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 al 00'and 2(ml00) construction to the following:
10.Static water level below top of casing: 30 (tt.) Division of Water Resources,Information Processing Unit,
If waler level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection 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:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service iCenter,Raleigh,NC 27699-1636
13a.Yield(gpm)
10 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 `
Forte OW-1 North Carolina Department of Environment and Natural Resources—Division of Watei Resources Revised August 2013