GW1-2021-03699_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS F wAT> Es_.,
FROM 'f0 DESCRIPTION
Well Contractor Name ft. ft.
4519—A ft. ft.
NC Well Contractor Certification Number
IS.OUTER CASING for"moth cased' e[Es OR LINER 1fi licible
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 78 rt. 6.25 1 in. #21 PVC
Company Name16 iINNER CASING<ORTUBiNGF eothermalelosed 10'0 "'€ A",
FROM
MCM-232W 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. ft. in.
3.Well Use(check well use): 17"'SCREEN <. S
Water Supply Well•• FROM TO DIAMETER; SLOT SIZE THICKNESS I MATERIAL
in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) -'�GIROUT-.To' ~MATERIAL 4 EMPLACEMENT METHO
D&AMOUNT
❑Irri ation 0 fc. 20 ft- Bentonite Pumped
Non-Water Supply Well:
f[. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation �,.19 SAND/GRAIL PACK`d a' `ficahle
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. tt.
❑Experimental Technology El Subsidence Control
;:,20.DRILLANG LOG attach additional iheets,if nece's" x'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock rype,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 78 ft. OVER BURDEN
08/13/2021 78 ft- 205 ft- GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft.
Daniel Hampton and Cheyenne Wiley -
ft. ft.
Facility/Owner Name Facility ID#(if applicable) n
ft. ft. �j
190 Triple R Drive, Canton it. ft. r �sit�gUni
Physical Address,City,and Zip ;F1:REMARKS,
. ..
Haywood 8655-07-1031 p j4
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one tat/long is sufficient)
08/13/2021
N W
Signature of cert3 Well Contractor Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,I hereby certifv 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 E]No copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the stature ofthe
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: 205 (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 Division of Water Resources,Information Processing Unit,
Ifwater 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) 6 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.
Forst GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
i
i
f