GW1-2021-07942_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 CLYDE BANKS
14.WATER ZONES '
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
4519-A it. ft.
NC Well Contractor Certification Number 15.'OUTER CASING for�ih-casedz�vells OR;;LINER�1f a licable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 160 it 6.25 ' i" #21 PVC
Company Name 16.INNER CASING'OR TUBING eothermat closed-lvo
322079 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: tt. 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: 'FROM TO DIAMETER: SLOT SIZE THICKNESS MATERIAL
ft. it. in.i
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in..
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEt-PACK,if a''licibic - -:'-.-- ;
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
El Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
'20.`DRILLING-1 OG attach additional sheets ifruecess _
❑Geothermal(Closed Loop) ❑Tracer FROM TO I DESCRIPTION color,hardness,soil/rock type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 60 ft' OVER BURDEN
05/31/2021 60 ft- 225 ft- GRANITE
4.Date Well(s)Completed: Well ID#
rt. rt.
5a.Well Location:
Brooke Huntley
Facility/Owner Name Facility ID#(if applicable) ft. ft.
TBD US 23 HWY, Mars Hill ft.
Physical Address,City,and Zip 21.REMARKS.,f.,' : q esb tgunil
Madison 9850-82-3293 r» " NR 5�cr;on
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N __O_
� 46 q %A J 06/1/2021
Signature of Cerli Well Contractor Date
6.Is(are)the well(s): RPermanent 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 END copy o(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 dus 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: 225 -(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,
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 m V Method of test: RIG 24c.For Water Supply&Injection Wells:
(gP ) 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
Fom GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013