GW1-2022-02925_Well Construction - GW1_20220228

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 FROxIROM RZONES - It r
"1'O DESCRIPTION
Weil Contractor Name ft. ft. 7
2
4519-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased',WgWiffitMif'
FROM TO DIAMETER TH MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 116 ft.
6 1/8 421 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-too "
361550-2 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable melt permits(i.e.County,State. Variance,Injection,etc.) f[ ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. fL❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) FIResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. 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 ft. ft.
❑Aquifer Test ❑Stoniiwater Drainage
ft, ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 116 e• OVER BURDEN
12-1-2021 116 rt• 245 rr• GRANITE
4.Date Well(s)Completed: -Well fD#
ft. ft.
5a.Well Location: ft. ft.
Mitchell Lusk ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Higgins Branch Lot 15 Mars Hill, NC 28754
Physical Address,City,and Zip 21.REMARKS
Madison 9758-32-0930
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)
N WMA R 1-20-2022
Signature ofCertjYt1 Well Contractor Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,I herebv cent fv 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 KNo copy ofthis record has been provided to the well owner.
If this is a repair.jilt out known ivell construction information and explain the nature of the
repair under#2l remarks section or on the back of this jorm. 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: 1 construction details. You may also attach additional pages if necessary.
Fa multiple injection or non-Hater supple wells ONLY with the sanee construction,you can
submit one,form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 245 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple"ells list al/depths ifdi(ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 40 (ft) Division of Water Resources,Information Processing Unit,
If miter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b. For Iniection 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 10 Method of test: RIG 24c.For Water Supply&Injection Wells:
tgp ) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 25 well construction to the county health department of the county where
constructed.
I'm i i GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013