GW1-2022-10252_Well Construction - GW1_20221111

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS 34 A . . ..... . � �. <�
FROM TO DESCRIPTION
Well Contractor Name ft, k.
4519-A
NC Well Contractor Certification Number 15c,0U�Ett CASiAlG.for iiiuttf ea'":tivelis t3tEsG11VR11. f s Iicakh:x .....r.
FROM TO DIAMF.TF.R THICKN S NIATERIAI,
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 62 ft- 16 vs I tin #21 PVC
Company Name 1b'IiViYER CA$1lY.C.�Ii'f'UBiNG eothermal�ctosetF•Ipo-`� ._-,,,.,.. �.�.� x�"'.,_.�
21120110959 FRONT '1'0 _DIAMETER THICKNESS NIATFRIAL
2.Well Construction Permit#: k. k. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft ft in.
3.Well Use(check well use):
Water Supply Well: FRONT To I DIAMETER I sLOT.SIZE THICKNESS I MATERIAL
ft. ft.❑Agricultural ❑Murlicipal/Public in
❑Geothermal (Heating/Cooling Supply) E�lResidential Water Supply(single) ft. ft. in.
PPY pPY( g
❑industrial/Commercial ❑Residential Water Supply(shared) 19;"GROUT :.. ... .. = ... �
FRONT TO MATERIAL EMPLACEMENT MF,TROD&AMOUNT
❑hTi ation 0 20 k• Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19�SsNA/GRAVEL PACK"d 'fable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft k
❑Experimental Technology ❑Subsidence Control
1Q:L►1ttLi,TNI fly-affaeti.atidltiiinai tsiid iteressacv z
❑Geothermal(Closed Loop) ❑Tracer FRONT TO DESCRIPTION color,hardness,soittrmk type. rain size,etc.
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 k. 62 k OVER BURDEN
10-6-2022 62 rt• 465 k GRANITE
4.Date Well(s)Completed: Well 1D#
ft. k.
5a.Well Location:
Jeffery Barnes ft. k. ,
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. NOV 1 022
Jeter Mtn Rd. ft. ft.
Physical Address,City,and Ziporg
Henderson 9536151135
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N W
10-10-2022
Signature-acerb' Well Contractor Date
6.is(are)the well(s): OPermanent or []Temporary By signing this frn'm.1 herehl•cer4fy that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 sA NCAC 02C.0200 Well Condruc•tion Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofthis record has been provided to the well owner.
If this is u repair,fill out kauwn weft construction infurmutiun and explain the nature of flue
repair under#21 remarlo•section or on the back of 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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:465 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3(d�02 and 1Ca 100D construction to the following:
10.Static water level below top of casing: 30 (ft,) Division of Water Resources,Information Processing Unit,
Ij 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 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
i
2econ Wells:
13a.Yield(gpm) 10 Method of test: RIG 4c.For Water Supply&Inj ti Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount• 20 well construction to the county he Alth department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013