GW1-2022-10200_Well Construction - GW1_20221111

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This tirrm can be used for single or multiple wells
I.Well Contractor information: S
GARRETT CLYDE BANKS FR WATER ZONES` CIO
FROM TODESCRIPTION
Well Contractor Name
ft. I ft.
4519-A ft. ft. i
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells}OR LINER(if a dcable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 67 it• 6 1/8 i° #188 STEEL
Company Namc 16.INNER CASING OR TUBING eothermal closed-loop),
WP22-103 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Counnt Stare. Variance,Injection.etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSI%E THICKNESS MATERIAL
ft. ft.❑A ricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single)
❑industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lnigation 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 a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stonrlwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/mck type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 67 ft. OVER BURDEN
4.Date Well(s)Completed: 10-10-2022Well iD# 67 tt• 125 it GRANITE
ft. ft.
5a.Well Location:
Hannah Hoxit
Facility/OHner Name Facility ID#(ifapplicable) ft ft
. R E C-0 E 11 IV'Ez mu-
15 Ernest Way Pisgah Forest, NC ft. ft.
Physical Address,City,and Zip 21.REMARKS
Transylvania 8597-79-8766-000
Counts Parcel Identification No.(PIN) Tj�l1!Q/~i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification'.
(if well field,one lat/long is sufficient)
—0-N W6 10-13-2022
Signature ofCerMted Well Contractor Date
6.is(are)the well(s): ❑O Permanent or ❑Temporary Br signing this form,I hereby cer•ti(b that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0109 or I5A NCAC 02C.0200 Well Constriction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E!]No copy a(lhis record has heen provided to the well owner.
It7lus is a repair.fill lint known well construclion in/brmalion and explain the nalure oJYhe
repah under#21 remarks section or at the back o)'this.16rnt. 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.
I'm ruuhiple injection or non-water supply wells ONLY with the sane construction.you can
subtmil one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 125 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
1 nw multiple wells list all depths ifdi#J rent(example-3 u),200'and 2G100') construction to the following:
10.Static water level below top of casing: 20 (ft) Division of Water Resources,Information Processing Unit,
Ii''mier level is above casing,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 in
ROTARY 24aabove, also submit a copy ofi 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: RIG 24c.For Water Supply&Injecti I 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.
kwol G W-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013