GW1-2023-01980_Well Construction - GW1_20230227

WELL CONSTRUCTION RECORD For internal Use.ONLY:
This lbrm can be used for single or multiple wells
I.Well Contractor information:
GARRETT CLYDE BANKS FR WATER`ZONES' "Oif TO DESCRIPTION
Well Contractor Name _ ft. ft.
4519-A ft. rt.
NC Well Contractor Certification Number 15.OUTER CASING(for.multi-cased4ells)'OR LINER(if a Geable)
FROM TO DIAMETER I THICKNESS I MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. UnknoNft 6 114 1: in #21 1 PVC
Company Name 16.INNER.CASING OR TUBING eothermal closed-too
MCM-358WR FROM TO DIAMETER: THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
Lisn all applicable troll permits(i.e.Couno,,State,Variance,Injection,etc.)
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER' SLOTSIZE THICKNESS MATERIAL
ft. ft. in•'
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) rt. ft. in.
b PP Y) PP Y( g ) ,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation ft. ft.
Non-Water Supply Well:
ft. ft. ,
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.,SAND/GRAVEL.PACK if a ltcablc
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwatcr Drainage
ft. ft. ,
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additionahsheets if necessary)e
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
ft. ft.
4.Date Well 9-19-2022 s)Completed: Well ID#
ft. rt.
5a.Well Location: ft. ft. _ a'
Jonah Pace
ft. ft.
Facility/Owner Name Facility iD#(ifapplicable)
ft. ft. E .J
52 Holly Hill Drive Canton, NC 28716 ft. ft.
physical Address,City,and Zip 21,REMARKS t^iP :50*6, '
Haywood 8665-88-7544 Drilled Well Deeper Well was 70'D'eep
County Parcel Identification No.(PIN) Drilled Well down to 205% Deep.
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
6/'well field,one]at/long is sufficient)
N W rm�o r VTVO AnAA 1/3/2023
Signature ofCer1-iM15J Well Contctorra Date
6.Is(are)the well(s): 2Permanent or ❑Temporary
Br signing this form,/hereby certify tlrnt the we//(s)was(were)constructed in accordance
with i5A 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 o/Yhis record has been provided t,the well owner.
/!`this is a re pair,fill out kn n vi well construction iglbrnnation and erplain the nature of the
repair under#21 rennarks 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 omltiple injection or non-water supply wells ONLY with the saute construction,von can
whntit once./brm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface 205 (ft.) 24a. For All Wells: Submit this,form within 30 days of completion of well
Far unultiple wells list all depths n,'/'dt[jerent(example-3@200'and 2@I00') construction to the following: i
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
illrater level is above casing,use'+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY:i 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
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,lUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&Injection 13a.Yield(-.pm)'
100 n Wells:Method of test: RIG r
Also submit one copy of this form within 30 days of completion of
131).Disinfection type: PILLS Amount• 20 well construction to the county health department of the county where
constructed.
Form G W-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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