GW1-2022-09439_Well Construction - GW1_20221017

i ,
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS FROMS�sIRIPTI, . ,. > . .:: .. . ..
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A
NC Well Contractor Certification Number 153t3U11}tLGA5fNG fdr. iuld.caledwel�s FROM O
DIAMETER, MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 et. 25 ft 6 1/8 ; ,in- #21 PVC
Company Name id<iNNER.t A$lNCxOR FURI1VO."4ofllet•msiclttsetirlpp,'`
2.Well Construction Permit#: 2021-20358-9-11895 FROM ft. TO ft. DIAMET.ER in THICKNESS MATERIAL
List all applicable well permits(1.e.County,State,Variance,Injection,etc.)
ft. ft. 'in.
3.Well Use(check well use):
17.;SCREEIV;w�l _ i,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in:
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) BResidential Water Supply(single)
❑IndustriaUCommercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
- -
❑Aquifer Recharge ❑GrouudwaterRemediation �19AlYD1GRALPAO#tda �'ib1e _._m _� __. .___.._ . ' _____-;
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
fr. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
2t1:1)l3t'GLt G`l)C aftaclr a8ditianafsheefsifnecessary- ......... �..,....»�«..�;
❑Geothermal(Closed Loop) ❑Tracer FRo51 TO DESCRIPTION color hardness,soillrock type.grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 25 ft. OVER BURDEN
9-22-2022 25 ft- 145 ft. GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
F=.r—•
5a.Well Location: ft. ft.
Owensby, Joesph I Kane ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft ft. OCT 1 r
Charley's Creek Rd ft. ft
Physical Address,City,and Zip
Jackson 8527-83-4528
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one IaUlong is sufficient)
9-22-2022
N W Cr
Signature ofcerti Well Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby certify that the well(s)ivas•(were)constructed in accordance
ivilh 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well 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 owner.
If this is a repair,fill out known well construction it formation and explain tiie nature of the
repair tinder#21 remarks section or on the back ofthis 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: construction details. You may also'attach additional pages if necessary.
For multiple ityectior or not-water supply wells ONLY with the.came construction,you can
submit one form. 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 multiple wells list all depths iij'di ferent(example-3@000'am12(a.,100') construction to the following:
10.Static water level below top of casing: 5 Division of Water Resources,Information Processing Unit,
If water 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
15 RIG 24c.For Water Supply&Injection
13a.Yield(gpm} Method of test:
Wells:
Also submit one copy of this form!within 30 days of completion of
13b.Disinfection type: PILLS Amount• 20 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