GW1-2022-10179_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This Form can be used for single or multiple wells
i
I.Well Contractor Information:
GARRETT CLYDE BANKS F4'wATERRODI 1'O.110
F DESCRIPTION
Well Contractor Name
ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number 15.OUTERCASING for multi-cased",'wells)OR LINER(if a hcable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 50 ft. 6 1/4 t 'n #21 1 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
MCM-281 W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable rrell permits(i.e.County,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.
❑Auricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test ❑Stonnwatcr Drainage
ft, ft.
❑Lsperinmcntal Technology ❑Subsidcnee Control
40.DRILLING LOG attach additional sheets if necessar
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock tv e,gmin sae,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 50 ft• OVER BURDEN
2-22-2022 50 ft• 805 ft• GRANITE
�.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
James Devlin
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
400 Peak Ave Waynesville, NC 28786 ft. NOV
1 p 20
22
I'hysical Address.City,and Zip 21.REMARKS
Haywood 8646-21-6763 Una
COanty Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field.one lat/long is sufficient) A i
N Wn J nmlk 10-24-2022
Signature ollen61K Well Contractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary Br signing this form,I hereby certf&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 ZNo copy q/this record has been provided a)the well owner.
1l"this is a repair.Jill oul known well construction inlhrmalion and explain the nalure of 1he '.
repair wider#2/remarks section or on the back gfthis 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 ifnecessary.
For mhtrlriple injection or non-water svrpplr welks ONLY with the scone construction,you can
submit ane%nnu. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: fp 05 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hbr mndliple ire/Le list all depths il'di/jcremt(example-3@200'and 2 1)l00') construction to the following:
10.Static water level below top of casing:
160 Division of Water Resources,Information Processing Unit,
(ftJ
1l"„vane,./eve/is above casing use•+- 1617 Mail.Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b. For Injection 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
(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
m 13a.Yield
(gP ) Method of test:1 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: 35 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