GW1-2023-00592_Well Construction - GW1_20230105

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This lint can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS 14,WATER ZONES P
FROM TO I DESCRIPTION
Well Contractor ft.
actor Name j
4519-A r` %
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased eivlls)'OR LINER if a licable'
FROJI TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 190 ft 6 1/4 in. #21 PVC
Company Name 16.IiNNER CASING OR TUBING.(geothermal closed400 )
W22-0166 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: f[. ft. in.
List all applicable well permits(i.e.Count),.State.Variance,hdection,etc.)
ft. ft. I in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM ro DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) F GROUT
ROhI I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 1" 20 ft- Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 0.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwatcr Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets.if necessary)
❑Geothermal(Closed Loop) []Tracer FROM I TO DESCRIPTION(color,hardness,soilfrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) 0 It. 90 ft. OVER BURDEN
12-6-2022 90 r`' 225 rt GRANITE
4.Date Well(s)Completed: Well ID#
ft. it. I
Sa,Well Location: ft. ft. :�
Peggy Brodersen
Facility/Owner Name Facility iD#(if applicable) ft ft.
114 Fred Parker Drive Old Fort, NC 28762
Physical Address,City,and Zip 21.REMARKS
McDowell 076100303728 This well was a self Certify.
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: !
(if well field,one tat/long is sufficient)
12-29-2022
N W
Signature of Certl Well Contactor Date
6.Is(are)the well(s): ❑O Permanent or ❑Temporary By signing this form,I hereby certifv 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 E]No copy gfthis record has been provided to the well owner.
ifthis•is a repair,fill out known well construction information and erplain the nature nfthe
repair under#21 remarks 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 injection or non-water s•upin v wells ONLY with the same construction,gout can
submit onefnr•m. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi(fcrent(example-3@200'and 2@1001 construction to the following: ,
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
q'water level 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: j
(i.e..aiger,rotary,cable,direct push,etc.)
Division of Water Resource's,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gym) 10 Method of test 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: 20 well construction to the county i eilth department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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