GW1-2021-00237_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
GARRETT CLYDE BANKS FROM ERzO:::
FROM "1'O DESCRIPTION
Well Contractor Name ft. fit.
4519-A fit. fit.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a Gcable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 179 ft. 6 1/8 #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed400
355541 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County.State. Variance,htjection,etc.)
fit. fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER' SLOT SIZE THICKNESS MATERAAI,
fit. ft. in:
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) FlResidential Water SuPP1Y(single) ft. f. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 tt. 20 fit. Bentonite Pumped
Non-Water Supply Well:
tt. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
El Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
'20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 fL 79 fit OVER BURDEN
9-28-2021 79 tt 225 fit GRANITE
4.Date Well(s)Completed: Well ID# fit. ft.
5a.Well Location: fit. fit.
CLAYTON HOMES 4383
tc. fit.
Facility/Owner Name Facility ID#(if applicable) ft fit J I
1062 TURKEY BRANCH ROAD MARS HILL NC 28754
rt. rt.
Physical Address.City.and Zip 21.REMARKS
MADISON 9746-53-5002
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification-
(ifwell field,one hat/long is sufficient)
N 10-22-2021
Signature of Cent Well Contractor Dale
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this form,1 herebv certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo coPy gf1his 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#2/remarks section or on the hack o.0hisform. 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 nun-water supply wells ONLY with the sane construction,iou can
submil one firm. 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 ifdiflerent('example-3@200'and 2 cil100') construction to the following:
10.Static water level below top of casing: 50 (fit,) Division of Water Resources,Information Processing Unit,
/f 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(gpm) Method of test:
$ RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this foim within 30 days of completion of
13h.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