GW1-2021-03776_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells f
1.Well Contractor Information: If
GARRETT CLYDE BANKS 1RVVATERZONES
FROM TO DESCRIPTION '
Well Contractor Name ft. ft.
4519-A ft. ft. i
NC Well Contractor Certification Number 15.'OUTER CASING for T!11'cased.Frells OR LINER i1 5""licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 tt. 84 ft 6.25 #21 PVC
Company Name 16.INNER CASiNG.ORTUBING eothermal;closed-loop)
356372 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt. in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: PGROUT
TO DIAMETER SLOT SIZE THICKNESS MATERIAL
in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) E lResidential Water Supply(single) in•
❑Industrial/Comrnercial ❑Residential Water Supply(shared) r TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 20 tt. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK:if applicable)
y„...:..
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 necess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiVrock type,gnin size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 84 tt OVER BURDEN
07/06/2021 84 ft 205 tt GRANITE
4.Date Well(s)Completed: Well ID#
ft. rt.
5a.Well Location: ft. ft.
Mitchell Lusk
Facility/Owner Name Facility ID#(if applicable) ft. ft. O
TBD Leatherneck Ridge Road ft. fL A , f"
Physical Address,City,and Zip
21.REMARKS: �.t"fl�
Madison 9758-32-0930 Portiono��"a�'`", �+'c''
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)
N W07/15//2021
Signature FILE Well Contractor Date
6.Is(are)the well(s): PIPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or END 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: 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 oneform. 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 ifdi[ferent(example-3@200'atd 2@I00') construction to the following:
10.Static water level below top of casing: 30 (ft•) Division of Water Resources,Information Processing Unit,
If water 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 m 15 Method of test: RIG 24c.For Water Supply&Injection Wells-
Also) Also submit one copy of this form',within 30 days of completion of
13b.Disinfection type: PILLS Amount: 20 well construction to the county hi alth department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013