GW1-2022-03906_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This limn can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS F4.WATER ZONES
FROM 'I'O DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(ifa lieable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 162 ft- 6 1/8 ! #21 1 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
WP21-120 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicuhle well permits(i.e.Cowur,State, Variance,hyection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑l\ ricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) 7Residential Water SuPPIY(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft' 20 it• Bentonite Pumped
Nou-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Tcst ❑Stonmwatcr Drainage
ft. ft.
❑Fxperinicntal Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 62 it' OVER BURDEN
3-10-2022 62 ft 485 ft GRANITE
4.Date Well(s)Completed: Well iD#
ft. rt.
5a.Well Location: ft. ft.
Kayla Lance ft. ft. P P:rr
l� e�
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Morton Gap Road Lake Toxaway, NC 28747 ft ft 02?
Physical Address,City,and Zip 21.REMARKS
Transylvania 8532391592000
COII111V Parcel Identification No.(PIN) 't'ti7``':'s:9 Ilj
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) __M
N 3-18-2022
Signature ofCeru Well Contractor Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,/hereby certijit that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.11200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or KNo caps of1his record has been provided to the well owner.
//this is a repair.fill out known ivell construction inJnrmalion and explain the nature of the
repair wider 421 remarks section or on,the back of this/ornt. 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 ifnecessary.
Far nudtiple injection or non-water supph.wells ONLY with the same construction.you can
vubmil one(a,.n,. Q SUBMITTAL INSTUCTIONS
9.'total well depth below land surface• 485 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For ranhip/e we/lc list all depths ifdillerent(exannple-3 a,200'and 2G100') construction to the following:
10.Static water level below top of casing: 80 (ft.) Division of Water Resources,Information Processing Unit,
/I walcr/evel is above easing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b. For Injection Wells ONLY: j 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,lUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1
13a.Yield(gpm) Method of test: 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: 35 well construction to the county health department of the countywhere
constructed.
Furors GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013