GW1-2023-00593_Well Construction - GW1_20230105

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This lb nr can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS -FRWATERZONES I i
OM I DESCRIPTION
Well Contractor Name ft. ft.
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4519-A ft. ft.
NC Well Cnn1YaC[Or Certification Number 15.OUTER CASING for multi-eased sirens)OR LINER(if a Gcable)
FROM TO DIAMETER THICKNESS aATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 110 ft• 6 1/4 i #21 PVC
Company Name , 16.-INNER CASING OR TUBINGM ('eothermal closed-loop) -
S V Vn,22-021 7 FRO TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:
List till applicable well permits(i.e.Couno%Stare. Variance,hyection,etc.) ft. ft.
in.
3.Well Use(cheek well use): 17.SCREEN
Water Supply Well: FRO\I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑MunicipaUPublic
in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18..GROUT .
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hritzation 0 ft- 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquirer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery []Salinity Barrier
❑Aquircr Tcst ❑Stonmwatcr 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,soiltrack type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain tinder 421 Remarks)] 0 ft 110 ft. OVER BURDEN
12-13-2022 110 tt• 605 ft. GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
Rick&Tammy Letterman ft.
Facility/Owner Name Facility iD#(ifapplicable)
109 Fairfield Lane Marion, NC 28752
Phvsical Address,City,and Zip 21.REMARKS
McDowell 078100945877r�
Countv Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(i f wel l field,one lat/long is sufficient)
12-14-2022
1rvu Q 4 lkA J
N W _
Signature of Cert'iftLd Well Contractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this form,1 hereby cer•tb that the weIlls)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 ONo copy gfthis record has been provided to the well owner.
ff ttis is it re pair fill out known well construction irrfbrmalion and erplaln the nature of the
repair under#21 remarks section a•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.
Fur multiple it jection or non-water supply wells ONLY with the same construction,you can
Submit onelarrrr SUBMITTAL INSTUCTIONS
9.•Cotal well depth below land surface• 605 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple irells list all depths r,'/'di(1erent(example-3@200'and 2 cd100� construction to the following:
10.Static water level below top of casing: 80 (ft.) Division of Water Resources,Information Processing Unit,
I/lrater 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 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
m 13a.Yield
(gp ) `Z Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
131).Disinfection type: PILLS Amount: 35 well construction to the county health department of the county where
constructed. '
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Fora G W-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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