GW1-2022-10215_Well Construction - GW1_20221111

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
4
I.Well Contractor Information:
GARRETT CLYDE BANKS 14.
FROWATER zoNEs
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A It. I ft.
NC'Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER(if a `Geable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 90 tt. 6 1/4 ! in #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed400
EH28804 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: _ rt• it• in.
List all applicable sell permits(i.e.County,State. Variance.Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
"`Pater Supply Well: FROM TO DIAMETER SLOT SIZE 'THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public in.
❑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- Bentoriite Pumped
Non-Water Supply Well:
rt. it.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO MATERIAL EMPLACEMENT METHODft.
❑Aquifer Tcst ❑Stormwater Drainage
ft. ft.
❑L'-xperinmcntal Technology ❑Subsidence Control
20.DRILLINGLOG attach additional`sheetsiinecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiltrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft. 90 ft. OVER BURDEN
10-27-2022 90 ft 205 ft GRANITE
4.Date Well(s)Completed: Well iD#
ft. ft. ,I
5a.Well Location:
Wallace Bradburn
Facility/Owner Name Facility iD#(ifapplicable) NOV I
ft. ft.
1537 Radar Road Rutherfordton, NC 28139 ft. fL IMorprIath,n t r.nWtpi 4 Unit
Physical Address,City,and Zip !Polk 126-2 3
21.REMARKS'
Cnunly Parcel Identification No.(PIN)
51).Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(il'well field,one fat/long is sufficient)
N w 11-7-2022
Signature of Certt WeII Contractor Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary Br signing this form,1 hereby certi(v that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.f1200 Well Consmiction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E!1No coPy of 1his record has been provided to the well owner.
//ihi.s is a repair.fill uul known well construction inlbnnation and erpluin the nature ofthe
repair under#21 renarks section or on the back o/'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 multiple injeetinn ur non-water.supply wells ONLY with the sane construction,you can
submit one%ortn. SUBMITTAL INSTUCTIONS
9.'I'otal well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
l'or multiple wells list all depths ff'Qkrent(example-3 ,200'and 2C100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
It nrner level is above easing,use•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For infection Wells ONLY: irl 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. anger,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
I
t 3:m.Yield(gpm) Method of
6 test: RIG 24c.For Water Supply&In.lection Wells:
Also submit one copy of this form Iwithin 30 days of completion of
131).Disinfection type: PILLS Amount: 20 well construction to the county health department of the county where
constructed.
Fortml GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013