GW1-2023-00594_Well Construction - GW1_20230105

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells +
I.Well Contractor information:
GARRETT CLYDE BANKS FROM
WATER ZONES
FROM TO DESCRIPTION'
Well Contractor Name
4519-A ' ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased Hells)OR LINER(if appGcable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 101 ft- 6 1/4 :in #21 1 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-too_
W22-1O170 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. i in.
List fill applicable nrll perndts(i.e.County,State,Variance,Injection.etc.) '
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) F GROUT
RODI I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable),.
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwatcr Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additioiiaFsheets if necessary),,
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 101 tt• ' OVER BURDEN
12-7-2022 101 ft, 405 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location:
Dawn Price Ross/Oakwood Homes ft. ft. `'�L
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. �l'L3
1500 Mount Hebron Road Old Fort, NC 28762
ft. ft.
' ,tr
Phvsical Address,City,and Zip 21.REMARKS
McDowell 064700671312
Countv Parcel Identification No.(PIN) l
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5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one]at/long is sufficient)
N6 12-14-2022
Signature of Ceru Well Contractor Date
6.is(are)the well(s): 9 Permanent or ❑Temporary By signing this fonn,I hereby cet•lifv diat the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCA`C 01C.0100 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or ONo copy gf1his record has been provided to the well owner.
10hi.s is a repair,jilt out known ivell construction iglbnnation and a-cplain the nature of the
repair under#21 rentarls section or at the back ofthisforu. 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 ifnecessary.
For multiple injection at,non-water supple wells ONLY with the sane construction,you can
subnnh one fora. SUBMITTAL INSTUCTIONS '
9.Total well depth below land surface•405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nndtiple wells list all depths ij'di(jerent(example-3 cu 200'and 3@/00') construction to the following: '
10.Static water level below top of casing: 60 (ft,) Division of Water Resources;Information Processing Unit,
If i ater level is above erasing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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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
I3a.Yield(-.pm) Method oftest:
2 RIG 24c.For Water Supply&In,jection.Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 35 well construction to the county lieallth department of the county where
constructed.
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Furor G W-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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