GW1-2022-06131_Well Construction - GW1_20220628

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 NN=STEWzo1ESrF�,";q
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A
ft. ft.
NC Well Contractor Certification Number 4A OUTER"' ItYG fprtnttlH=cssed tiClts'OR`LINER'rliu iicaple, h l
FROA1 TO DIAMETER THICKNESSMATERIALCLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 48 ft. 6.25 1O #21 1 PVC
Company NameT6,l VNER Gd5tnG=OR 711B1NG- `eiitheriiia[clpsed=tali
P Y w. iQr
NRH-246W FROhI TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable melt permits(i.e.County,State,Variance,Injection,etc.) ft. f[. in.
3.Well Use(check well use): 17:SCRECN,
v,
Water Supply Well: FROM TO DIAMETER SLUT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) f`' f` in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) VlKR,,,GROU i§,$W. ' `f
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
1111,; ation 0 et. 20 fr. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation19:;SANDICRA�?)LFYr1GK-it:a" licaSlilekf ..<<.,,asp❑ FROaI TO MATERIA EMPLACEMENT 51ETHOD
L
Aquifer Storage and Recovery ❑Salinity Barrier ft it
❑Aquifer Test ❑Stomrwater Drainage
❑Experimental Technology ❑Subsidence Control ft. ft.
l0DR1I.Ti1Nti`1>tlG;attachaddiNaiixt'sheets`•ifnecessary;kyc��.�:F�«t�
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness.soillrock tare ram size,etc.)
❑Geothermal (Heating/Cooling Return) El Other(explain under#21 Remarks) 0 et. 8 ft. OVER BURDEN
04-14-22 48 tL 425 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location:
RICKY TEAGUE ft. ft. ter- r ..: J
Facility/Owner Name Facility lD#(if applicable) ft. ft.
HARLEYS COVE 22
ft. ft.
Physical Address,City,and Zip
R14s
HAYWOOD 8710-63-1538 z,��Ei�A ��
„t
Y
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one ladlong is sufficient)
N `l, 05-23-2022
Signature of C4'iw.�,,C.Aractur Date
6.is(are)the well(s): RPermanent or ❑Temporary By signing min•this firm,nrm,1 herehv certt that the well(s)was were constructed in accordance
with ISA NCAC 02C.0100 nr 15.4 NCAC 02C.0200 M ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo copy of this record has been provided to the well outer.
7f this is a repair,fill and known well construction irrformalian and explain the nature of the
repair under#21 renmrkv section or on the back ofthis faro,. 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.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 425 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths ifdiJjrent(example-3(dj200'and 2(ar100) construction to the following:
10.Static water level below top of casing• 20 (ft.) Division of Water Resources,Information Processing Unit,
IJ'nvier 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(gpm) 50 Method of test: RI G
24c.For Water Supply&Injection Wells:
PILLS O Also submit one copy of this form within 30 days of completion of
20 13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013