GW1--06098_Well Construction - GW1_20230921

•
1
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: , .
GARRETT COLLIN BANKS `FRO WATER o DESCRIPTION
\Nell Contractor Name ft. ft. i
4519-A ft. ft.
NC Well Contractor Certification Number 1.5 OUTERICASING(f'or'muln easedti#ells)OR,LINER(If applieablei=- . - '
OM TO
CLYDE SAWYERS & SON WELL & PUMP INC +1 it. 38 ft DIAMETER m•
THICKNESS MATERIAL 1PVC
Company Name QQ '16.1NNERCASING:OR TUBING_(eidl ermal closed lebp)"; 41•'
3-0661 FROM TO DIAMETER THICKNESS MATERIAL
055-202
2.Well Construction Permit#: 3 ft. ft. in.
List all applicable well permits(i.e.County,State,Variance.Injection,etc.) -
ft. ft. in.
3.Well Use(check well use): e17:SCREEN ..
Water Supply Well: FROM , TO DIAMETER SLOT SIZE THICKNESS MATERIAI.
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) el Residential Water Supply(single) ft. tt. in.
PP Y) PP Y(sin le
❑industrial/Commercial ❑Residential Water Supply(shared) :fS.GROU'L.. `..rt <
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft• 20 It. Bentonite Pumped
Non-Water Supply Well:
ft. It. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.`S:AND'IGRAVEL''PACK.(if applicable) '..., s
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Stooge and Recovery ❑Salinity Barrier ft- ft.
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
-�20.`DRILLING••LOG(attachaddittonafslieetsifnecessaryl -
❑Geothermal(Closed Loop) • ❑Tracer FROM TO DESCRIPTION(color,hardness,soilrock type,groin size,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 it• 38 it- OVER BURDEN
07/06/2023 38 ft. 605 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft. " +„�
Sa.Well Location: 't.+....v,/1.ti I +te '""1.)
ft. ft.
thimothy Sheehan&Kerri Reis ft. ft. SEP 2 i 2023
Facility/Owner Name Facility ID#(if applicable) ft. ft.
208 Old Cabin Creek Rd, Zirconia, 28790 'n ; ;;r.n'f,'-'2'!,'°p3 fry
ft. ft. MCA O ,
Physical Address,City,and Zip 2 1:RE LARKS. • , _ :='- • ..
Henderson 9565016944 Well was self certified
County Parcel Identification No.(PM)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W 07/20/2023
Signature ofCern Well Contractor h Dale
6.Is(are)the well(s): OPermanent or ❑Temporary I
By signing this farm,I hereby certifi•that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or/54 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo 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:
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.
For multiple injection or non-water.supply wells ONLY with the.mute construction,_vim can
submit one form. SUBMITTAL INSTUCTIONS
G I
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@,)200'and 2 a7100') construction to the following: i
10.Static water level below top of casing: 25 (ft) Division of Water Reso rces,Information Processing Unit,
If water level is above casing,use"-s' 1617 Mail Service Center,Raleigh,NC 27699-1617
i ,
11.Borehole diameter: 6.25 (in.) 24b.For injection Wells ONLY: Iln1addition 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
(i.e.auger,rotary,cable,direct push,etc.) I ,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
(gpm) 1�2 RIG 24c.For Water Supply&Injection Wells:
m 13a.Yield Method of test:
Also submit one copy of this forth within 30 days of completion of
13b.Disinfection type: PILLS Amount: 20 well construction to the county he,Itlr department of the county where
constructed.
1
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water R sources Revised August 2013