GW1--06078_Well Construction - GW1_20230921

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT COLLIN BANKS glktrERtZONEsS3.. '
4:$�SW OD! ."' :MVO:,
FROM _ TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft.
I
NC Well Contractor Certification Number $ OUd$kCAStSiQrei italtl=as .. lls"`.OKi 14git{iPs 1cl ljie)5.•��
FROM TO DIAMETER THICKNESS MATERIAL.
CLYDE SAWYERS & SON WELL & PUMP INC +1 n. 51 ft. 6 1/4 I I". #21 Pvc
Company Name ;1e1NNER Ce S( URItfB113G' t erl anal clo'sed>trpp) ""'
MCM-171 W •
FROM 'r0 DIAME•1'P:R 'THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. , in.
List all applicable well permits(i.e.County,State,Variance,injection,etc.) ft. ft. in.
3.Well Use(check well use): .` 7:CSC:REEiV 414 u^ ,s f",.. 44
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public _
ft. fL in.
❑Geothermal((Heating/Cooling Supply) Residential Water Supply(single)
❑IndustriaUCommercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft' 20 ft• Bentonite Pumped
Non-Water Supply Well:
ft. ft. Cap Top with Bentonite Chips
OMonitoring [Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 9 SAND/GRAI EL PMErtif applis it e, , , ,NM ,,y.
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage •
ft. ft.
❑Experimental Technology El Subsidence Control
2011D ILTANGVOill{mach'Pifilditton s is trneces`i*1
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size,ete.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 51 ft. OVER BURDEN
7-13-2023 51 ft. 605 ft. GRANITE
4.Date Well(s)Completed: Well ID# ft. ft. ^ R., - _
5a.Well Location: ft. ft. Z.--L� >?yt�3'tz L�`
Jeff Moore "
ft, fL i Cp
Facility/Owner Name Facility ID#(if applicable) ft. ft. S C` 1 2023
Off Wiggins Road Canton, NC 28716 .ft. ►i :ic�R�i4f,-� .k (;,,
Physical Address,City,and Zip MMEIVIf - ` h ^•p
Haywood 8677-47-8308 Well was self certified i.
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
N W C '�//./�] 7-14-2023 •
Signature of Celt Well Contractor : Date
6.is(are)the well(s): OPermanent or ❑Temporary By signting this form,1 hereby certify 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 ©No copy of this record has been provided topic,well oxncr.
If this is a repair,fill out known well construction information and explain the nature of the 1,
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
S.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: 605 (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 n O0'and 24100') construction to the following: l -
1
10.Static water level below top of casing: 120 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1 '
11.Borehole diameter: 6'25 (in.) 24b.For Injection Wells ONLY:1 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 Cleo ter,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
L3b.Disinfection type: Amount: 25 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