GW1-2021-06551_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS `FR NATERZONES PTIO
FROM TO DES CRI PTION
Well Contractor Name ft. ft.
4519-A
NC Well Contractor Certification Number 15.OUTER CASING Tor multi-eased wells OR LINER i,a` licable
FROM TO DIAMETER THICKNESS MATERIAL.
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 85 ft- 6.25 in #21 1 PVC
Company Name I6'.INNER CASING OR TUBING eAthermal closed-loo
362810—� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: it• ft. in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): i7.
Water Supply Well: FROM 'to DL4MF.TER SLOT S17.E THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) BResidential Water SuPPIY(single) in.
❑Industrial/Commercial ❑Residential Water Supply(shared) �48•GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 rt. 20 It- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if a licable'
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
DRILLING LOG attach additional sheets if oecess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,g rain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 85 ft. OVER BURDEN
09/20/21 85 rr• 325 rr• GRANITE
4.Date Well(s)Completed: Well lD#
ft. ft.
5a.Well Location: ft. tt. LJ
CC Customs, INC
Facility/Owner Name Facility ID#(if applicable)
ft ft. T
Country Dr., Lot 10 ft.
UI1ti
Physical Address,City,and Zip ; SIII
11.REMARKS =;� Inf0t
Madison 9757-14-5500 portion
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification•
(ifwell field,one ladlong is sufficient)
N W nAA
09/20/21
Signa1L;r—eofCer1i1K Well Contractor Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this.jorm,1 hereby certift 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 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 ofthis 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 same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 325 —(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 30 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 lniection 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) Method of test:
5 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.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013