GW1--06193_Well Construction - GW1_20230922

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells i
1.Well Contractor Information: I
GARRETT COLLIN BANKS
FROM TO DESCRIPTION
Well Contractor Name ft. ft. I
4519-A ft. ft. ! I
b 5 f ;` 3
NC Well Contractor Certification Number
itVEIt GISJA 0 lkli GU ti Ot II Alleabtel$' A
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 24 ft• 6 1/4 I #21 Pvc
��
Company Name 1~kt�'G1�ST1�IG,C1R�Ti�$111"((y`s(��t`h�ruie['ctosett=t4frt�3A . ,,".. �' . `4',,..
WP23-098 FROM DIAMETER 'THICKNESS r%IATICRIAI.
2.Well Construction Permit#: ft. ft. ! in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) Ct ft. in
3.Well Use(check well use): gmsofoop - ,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS , MATERIAL
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DAgricultural ❑Municipal/Public ft. ft. it1
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 7fit TxM lOi� � � �� __.,
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNTDirrigation
Non-Water Supply Well: 0 ft' 20 ft' Bentonite Pumped
❑Monitoring DRecovery ft. ft. I' Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑A uifer ❑Groundwater Remediation ti
q Recharge �; tSvUt�lt��la1(.�P;�erK�(ii�ajitiiieatle}��.�,�, ,;
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery ❑Salinity Barrier ft. ft. I
DAquifer Test ❑Stonnwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control 2,tMd IWEtiG(at ,ii ififftstitec fiat,:
t
❑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- 24 ft i,, OVER BURDEN
8-16-2023 24 ft• 705 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
Sa.Well Location: ft. ft. —' ` ""1:
Wendy Hill ft, ft. i 4o I C.t. �7 t-i..
Facility/Owner Name Facility ID#(if applicable) ft. ft. SEP p 2, 2 2023
71 Green Valley Road Penrose, NC 28766 ft ft. ,,Cf
Physical Address,City,and Zip OrTalttWitla ' sue.., +^1
Transylvania 9517-91-4668-000 ,>
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certificati
(if well field,one lat/long is sufficient) ConfIctf6
N W8-24-2023
Signature ofCetl Contractor i Date
6.Ts(are)the well(s): ElPermanent or ❑Temporary
By signing this firm,1 hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo 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
S.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 saute construction,you can
submit one form. SUBMITTAL INSTUCTIONSII
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9.Total well depth below land surface: 705 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi�rent(example-3@200'and 24)100) construction to the following: 1
10.Static water level below top of casing: 300 (ft) Division of Water Resources,Information Processing Unit,
limiter level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY:i hi 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
1�2 RIG 24c.For Water Supply&Injectio I Wells:
13a.Yield(gpm) Method of test:
PILLS Also submit one copy of this forin within 30 days of completion of
13b.Disinfection type: Amount: 35 well construction to the county helalth department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013