GW1-2021-06223_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD � ! For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT BANKS � J FR.yVATERzoNEs I i
—� FROM TO DESCRIPTION
Well Contractor Name
4519-A P v �t rC�� ft. ft.
3sOa��e� 15.OUTER CASING,(for multt-cased wells O!1L,1 R ifa licable
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WE L PI�IIP INC +1 ft. 32 ft- 16.25 #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
MCM-396 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable we//permits(t.e.County,State,Variance,Injection,etc)
ft. ft. 'in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. 1t. in•
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) f. ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ' 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO .MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
[]Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 32 ft. OVER BURDEN
6-17-2021 32 1" 465 fr• GRANITE
4.Date Well(s)Completed: Well ID#
• ft. ft.
5a.Well Location: ft. ft.
AUSTIN&MEGGAN MORGAN ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
244 VISTA LANE CANTON, NC 28716 ft. ft.
Physical Address,Citv,and Zip 21 REMARKS
HAYWOOD 8658-52-4414
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)
��0 tt o � 6-21-2021
N W 1'`7t,ttry
Signature of Certified VTell Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary Hy signing this farm, l hereby certify that the wells)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 E]No copy oJ'dns record has been provided to the well owner.
l/Ihis is a repair,/ill oul known well construction information and explain the nature oflhe
repair under 21 remarks section or on the back a/thts 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.
hhr nndtiple oyeelion or non-uratersupply wells ONLY with the sane construction,you can
submit oneJorn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 465 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
1•br nnhip/e u'e/Is list all depths it dl fferenl(example-3 ct 200'and 2 a/00') construction to the following:
10.Static water level below top of casing: 80 (ft.) Division of Water Resources,Information Processing Unit,
I/hater level is above casing,use"4" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b. For Infection 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 Center,Raleigh,NC 27699-1636
13a.field(gpm) 3 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: 35 well construction to the county health department of the county where
constructed.
For GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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