GW1-2023-01996_Well Construction - GW1_20230227

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS FROM WATER FROMTO DESCRIPTION
Well Contractor Name
ft. ft. `
4519-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased 1Gelis)OR LINER(if a licable)-
FROM TO DIAMETER i THICKNESS MATER
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 184 ft. 6 1/4 ! in- 1 #21 1 PVC
Company Name 16.INNER CASING OR TUBING eotherinal closed-loo ,
SW21-0129 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable trell permits(i.e.County,State.Variance,h jection,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
ft. ft. in.
❑ m Geotheral(Heating/Cooling Supply) OResidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply 18.GROUT"
pp y(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 fc. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring El Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)'
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20..DRILLING LOG(attach additional sheets if nice ssar '
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type.grain sue,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 84 ft OVER BURDEN
12-10-2022 84 ft- 605 ft- GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft. •-•
Devin & Elisabeth Henson ft. ft. i %,'!z-` �
Facility/Owner Name Facility iD#(ifapplicable) ft. ft — 9 023
221 Sawmill Road Old Fort, NC 28762 ft. ft.
Phvsical Address,City,and Zip _ .r t
21.REMARKS, O;l. :t• ;�;-"..
Mcdowell 067900310059 +�`�`� '
County Parccl Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one ha/long is sufficient)
N W 01/04/2023
Sjgnatt7r_eofCerMft4 Well Contractor Date
G.Is(arc)the well(s): OPermanent or ❑Temporary Br signing this form,1 hereby cert�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!1No copy gf1his record has been provided to the well owner.
/(this is a repair,.lill out known well construction information and nrplain the nature ofthe
repair under 921 remarks section or on the back ol'thisJorm. 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.
1vn-muhiple injection or non-u•arer supple wells ONLY with the same construction,you can
crdm7it one fmnm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 605 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple n e!/s list all depths iJ'dilJererrt(exautple-3�00'and 2 u✓100� construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
l/'❑•vier level is•whore casing,use•'+^ 1617 Mail Service Cienter,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
13a.Yield(gym) 15 Method of test: RIG
24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form iwithin 30 days of completion of
13b.Disinfection type: Amount: 35 well construction to the county health department of the county where
constructed. 11
Form Uw-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013