GW1-2022-07937_Well Construction - GW1_20220823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This formm can be used for single or multiple wells
I.Well Contractor information:
GARRETT CLYDE BANKS 14.WATER ZONES
FROM '1'O DESCRIPTION
Well Contractor Name - ft. ft.
4519-A `t.
cased IN
\C Well Contractor Certification Number 15.OUTER CASING for multi- `wells)OR LER(if a. 7icable
FROM TO D1.4METER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 23 rut 6 vs i" #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
WP22040 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County.State. Variance,l jection.etc.) ft. ft.
in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER. SLOT SIZE THICKNESS MATF:RIAh
ft. ft. in.
❑,Aericultural ❑Municipal/Public
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water SuPP1Y(single)❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ic. 20 u• Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquiler Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experinmcntal 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#21 Remarks) 0 ft. 23 ft. OVER BURDEN
6-27-2022 23 ft 145 ft GRANITE
4.Date Well(s)Completed: Well 1D#
5a.Well Location: ft.
Nathaniel Hall ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Unit
Slick Fisher Road Lake Toxaway, NC 28747 ft it. <•�, re
Physical Address,City,and Zip 21.REMARKS
Transylvania 8514-94-8700-000
CUanIV Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lot/long is sufficient)
7-6-2022
N W
Signature of Cer-111RJ Well Contractor Date
6.Is(are)the well(s): 2 Permanent or ❑Temporary By signing this form,1 hereby certiJv that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No copy gfthis record has been provided to the well owner.
//this is a repair.fill out known well construction information and erplain the nature of the
repair under#2/remarks section or on the hack of this form. 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 nmhiple injection or non-water.supply wells ONLY with the sane construction,you can
submit one forte. SUBMITTAL INSTUCTIONS
9.'total well depth below land surface: 145 -(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nuilliple wells list all depths il'dlfferent(exaniple-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,
1llrater level is above ceasing,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'.n
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
13tt.Yield(gym) /
7
Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13h.Disinfection type: PILLS Amount: 20 well construction to the county health department of the county where
constructed. f
Foro1 C W-I North Carolina Department of Environment and Natural Resources—Division of Water,Resources Revised August 2013