GW1-2022-03907_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This hvin can be used for single or multiple wells
I,well Contractor Information:
GARRETT CLYDE BANKS FR WATER ZONES
FROM 'I'O DESCRIPTION
Weil Contractor Name
ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a Geable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft' 161 ft- 6 1/8 1" 1 #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
WP21-163 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: fc. ft. in.
List all applicable trell permits(i.e.County,Slate. Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER[ SLOT SIZE THICKNESS MATERIAL
in:
❑Agricultural ❑Municipal/Public
❑Geothenmal(Heating/Cooling Supply) Residential Water SuPPIY(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrrieadon 0 ft' 20 ft- BentOnite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aqui ter Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
ft, ft.
❑l'sperimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional'beets if necessary)
❑Geothermal(Closed Loop) ❑TTacer FROM TO I DESCRIPTION color,hardness,soiUmck type, rein size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) 0 r`' 61 ft OVER BURDEN
3-15-2022 61 f` 105 f` GRANITE
4.Date Well(s)Completed: Well ID#
ft. rt.
Sa.Well Location: ft.
Jonathan Morrow ft. ft.
Facility/Owner Namc Facility ID#(ifapplicable) ft. ft. APR ?02?
572 Holiday Road Pisgah Forest NC 28768 rt. rt.
Physical Address,City,and Zip 21.REMARKS
Transylvania 9518682297000 y�6 l`'
Cnumv Parcel Identification No.(PIN)
51).Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
1 i'well field.one lat/long is sufficient)
N w
3-21-2022
Signature ofCerMMlfJ Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certq( 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 IfINO cope gfthis record has been provided to the well owner.
lfdtis is a repair.fill out known ire/l construction in/inrmation and explain the nature o/7he
repair under#21 remarks section or on the back o/'this,/orm. 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.
Fnr mulliple injeclion or non-traler supply wells ONLY With the sane construction.you can
,111,171il one,form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 105 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Fm mulliple ur//s list all depdes d di(/crent(exantple-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 15 (ft) Division of Water Resources,Information Processing Unit,
//waver level is above casing.Ilse„+" 1617 Mall 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.Weil 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)
100 Method oftest: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
136.Disinfection type: PILLS Amount: 25 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
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