GW1-2021-06586_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
414.'WATER ZONES
GARRETT CLYDE BANKS DESCRIPTION
FROM TO DESCRIPTION
Well Contractor Name ft. tt. !
4519-A
NC Well Contractor Certification Number 15rOUTER CASING for uI cased Iti'OR LINER.'If a-licable
FROM nti
TO DIAMETER I THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 84 ft 6.25 i"• 1 #21 PVC
Company Name 16.INNER CASING OR TUBING eotheniaal closed-loo" "—
N RH-221 W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
ft. tt. in.
3.Well Use(check well use): 17.SCREEN
Water supply Well: FROM TO DIAMETER; SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geotheral(Heating/Cooling Supply) E�lResidential Water Supply(single) ft. tt. in.
m
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAV.EL PACK:if applicable)
m
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Tt. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additionahsheets if;necess
❑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. 84 ft. OVER BURDEN
06/29/2021 84 ft- 465 ft. GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location:
William Bradley Allen
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Split Pine Cv.
ft. ft.
Physical Address,City,and Zip '21:REMA12K5
Haywood 8721-97-7064
1p5cl
County Parcel Identification No.(PIN) D%ry
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•CertificaJ. We1l4.n1.actor
(if well field,one lat/long is sufficient)
N 06/30/2021
Signature of C ; Date
6.Is(are)the well(s): RPermanent or ❑Temporary By signing this form,1 hereby certilv,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 ElNo copy ofthis record has been provided to the well owner.
Ifthis 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: 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: 465 —(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(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,
lfwater 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
13a.Yield(gpm)
4 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: 20 well construction to the county!health department of the county where
constructed. i
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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