GW1--04478_Well Construction - GW1_20230713

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT COLLIN BANKS FROM
FROM _ TO DESCRIPTION
Well Contractor Name ft. ft. I 1 4519-A ft. ft.
NC Well Contractor Certification Number :15.r`OUTER CASING(0ir,inidt-cased i'clls)OR LINER(if ap p hcable) . ,
FROM TO DIAMETER; THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 60 ft• 6 1/4 ' in. #21 Pvc
Company Name .-•L6.'INNERCASINGOR=TUBING(geo op).°hermahclosed lo ,'i •,
SW21-O598 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) H. ft. in.
3.Well Use(check well use): :�17.SCREFN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public H. ft. in.
tf. in.❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.-GROU1. „ .„ .. ''''''';';'1':' ': ' • ,'''-
FROM TO w MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery _
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation ''19.SAND/GRAVEL PACK'(ifapplicahle) ,
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
;-20.DRILLING LOG(attach additional"sheetsif necessary -_;', "e••
❑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 ft• 60 ft. OVER BURDEN
06/19/2023 60 ft• 405 ft• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft. �^•; rt: --,z.,,,
5a.Well Location: i,�'„ ---{ , F"
Jack & Kathleen Graves ft. ft. JULacility/Owner Name Facility 1Dif(if applicable) ft. ft. ,1 i .• 2023
92 Sky Falls Trail, Old Fort, 28762 ft. ft. lri/cA'bJZn,::',3
of
Physical Address,City,and Zip
:21.REMARKS ll1 sl y i
<
McDowell 063800154232 Well was self certified
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)
N W 6 20 2023
Signature ofCern Well Contractor Date
6.Is(are)the well(s): CIPermanent or ❑Temporary
By signing this fount,I hereby cer0.that the well(.)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or 15A NGtC 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:
1 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 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:405 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ffdi(ferent(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,
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
RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 15 Method of test:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 20 well construction to the county health department of the county where
constructed. 1
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Form OW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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