GW1-2022-09523_Well Construction - GW1_20221017

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This firm can be used for single or multiple wells
I.Well Contractor information:
14. ONES
GARRETT CLYDE BANKS FROM ER 'to r0 DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft, ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER'(if a 6cable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 78 ft. 6 1/8 ' i" #21 1 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-log
MCM-336W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. fL in.
List all applicable it-ell permits•(i.e.Count),,State. Variance,Injection,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.
❑Agricultural ❑MunicipaVPublic
❑Geothermal(Heating/Cooling Supply) El Residential Water SuPP1Y(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) Ill.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lnigation 0 fr. 20 rut. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEM ENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stornwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary),
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sollfrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain tinder#21 Remarks) 0 ft. 78 ft. OVER BURDEN
7-20-2022 78 rc• 485 rc• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
Sa.Well Location: ft. ft.
Jerry Trull ft. ft.
Facility/Owner Name Facility iD#(ifapplicable) ft. ft. ` `� a a a2
1101 Wills Way Canton, NC 28716 ft. OCT 17 2022
Phvsical Address,City,and Zip 21.REMARKS
Haywood 8654189624 tnfi3�:T,3,; Pray 'ing Unit
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
lif'well field,one lot/long is sufficient)
N w 9-12-2022
Signature 0 f Certi'11K Well Contractor Date
6.is(are)the well(s): ❑O Permanent or ❑Temporary Br signing this form,i hereby certi(v that the well(s)was(were)constructed in accordance
With 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction StandardT and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy gfthis record has heen provided to the well owner.
ff 1his is it repair,fill out known well construction information and e-rplain the nature of die
repair under#21 remarks section or on the back ojthis•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.
h,or undtiple injection or non-to•ater aupplt•wells ONLY with the satire construction,you can
snhntii one jornn. 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 inithiple wells list all depths ffilf Brent(example-3 n 200'and 2G100') construction to the following:
10.Static water level below top of casing: 50 (ft,) Division of Water Resources,Information Processing Unit,
I11rater level is above caving,use"+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
1
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 ithis 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( m Method of test:
dp ) 1 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 county where
constructed.
Forgo GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013