GW1-2023-00596_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
1.Well Contractor Information:
GARRETT CLYDE BANKS F4.WATER ZONES:
FROhI TO DESCRIPTION
it. J' Well Contractor Name It,. �
4519-A
NC Well Contractor Certification Number 15.OUTER CASING for indlti-casedlwells)OR LINER(if a Gt"I
FROM TO I DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 85 rt. 6 1/4 : i #21 PVC
Company Name 16.INNER CASING OR TUBING geothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: SW21—0069 ft. ft, I in.
List all applicable well pennits(i.e.Counly,State.Variance,hyection,etc.) ft. (1. in.
3.Well Use(check well use): "17:SCREEN'
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATF,RIAI,
it. ft. in.
❑Agricultural ❑Municipal/Public
f. ' - ft. in.
❑Geothermal(Heating/Coolnd Supply) IResidential Water SuPP1Y(single) :GROUT..-❑Industrial/Commercial ❑Residential Water Supply(shared) FROM TO MA
TERIA L '
EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL`PACK if applicable)
FRO\I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aq«if'cr Tcst ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.`DRILLING LOG attach adrlifioialsheets if necessary),
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiVrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 85 ft. OVER BURDEN
1-10-2022 85 ft, 805 ft- GRANITE
4.Date Well(s)Completed: Well iD#
ft. ft.
5a.Well Location: ft. ft.
Melissa Biggs
Facility/Owner Name Facility ID#(if applicable) ft ft. W; .'�, 5 ?' $�-•A
2488 Catawba Falls Parkway Black Mtn, NC 28711
Physical Address,City,and Zip 21.REMARKS
Mcdowell 063800158855 {
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one hat/long is sufficient) 22.Certification: l
N W 11-30-2022
Signature of Cerfl'ff6 Well Contractor Date
6.Is(are)the well(s): R Permanent or ❑Temporary BY signing this fonn,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.0100)Drell Constniction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided tolthe well owner.
lflhis is a repair,fill out known well construction information and explain the nature ofthe i
repair under#21 remarks section or on the back of this fonn. 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-uwter supply wells ONLY with the same construction,Lou can I
submit one fonn. SUBMITTAL INSTUCTIONS '
9.Total well depth below land surface: 805 (ft.) 24a. For All Wells: Submit this, form within 30 days of completion of well
For nuthiple wells list all depths#'different(example-3 rUil�00'and 2@100) construction to the following:
10.Static water level below top of casing: 200 (ft.) Division of Water Res'urces,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter.- 6.25 (in.) 24b.For Infection Wells ONLY- in addition to sending the form to the address in
ROTARY 24a above, also submit a copy of tfiis form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) I I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1 RIG 24c.For Water Supply&Injectio
13a.Yield(gym) Method of test: Injection Wells:
Also submit one copy of this fiitm within 30 days of completion of
PILLS
13b.Disinfection type: Amount: 35 well construction to the county htealth department of the county where
constructed.
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Form G W-I North Carolina Department of Environment and Natural Resources—Division of WaterlReIsources Revised August 2013
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