GW1-2023-02013_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 TO D 11 FR.M1�T>rR SC.z..IPn.
FROM ES
Well Contractor Name ft. fr.
4519—A ft. ft.
NC Well Contractor Certification Number '=`l5_10 l l` t1 CilutNo fdemulti ciisetl wells`OIt°G11V t1'if.'a"'Sable);<:':ii``�U2'i zz
FROM TOI DIAMETER; TRICKNESS MATER1.41,
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. 70 ft• 6 1/4 I' 'in- #21 PVC
Company Name ..:16IN1?lERGtC [iYGUR:TUBIN(i_ `cbfticeiriEstRsed=tPo
WP 22-144 FROM DIAMETER THICKNESS MATERIAL
f[. ft. in.
2.Well Construction Permit#: ,
List all applicable well permits(i.e.County,Slate,Variance,Injection,etc.) ft. ft in
3.Well Use check well use):
( ..............
Water Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS I ATATERIAL
fr. ft.❑Agricultural ❑Municipal/Public in!
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. tt. inl
❑lndustrial/Cotmnercial ❑Residential Water Supply(shared)
Pp y( FROM TO MATF.RTAL EMPLACEMENT METHOD&AMOUNT
❑lr,; ation 0 ft' 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation �'L9`z:Sit1VD/U1fi3'9�+' ,�P.AGK'if a`" `��h]e===:=<i=s='�:;#'3;:.:. �:`':=-'::="=-:`:=-:_:�*.::-,�:...;.r•.�>��':
FROM TO ALITERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stomiwater Drainage
ft. fr.
❑Experimental Technology []Subsidence Control
2U-bTt1C :1`L1G a[faeisarldltitiitak'sliee[s'ilnece§sa':'"
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTTON color,hardness,soiurmk tr a grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 70 ft. OVER BURDEN
ft ft•
4.Date Well(s)Completed: 01-12-2023 Well ID# 70 505 GRANITEet. ft.
i
5a.Well Location:
DWAYNE SMITH fr. ft. I e>ia.. f►..-; f� .�S
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. FEB 9,
220 DUFF COVE RD BREVARD , NC ft. ft.
PhysicalAddress,Add City,and Zip
TRANSYLVANIA 8595-91-3930-00
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N 01/24/2023
-A R.
Signature of Ceit—ifte Well Contrutor I Date
6.Is(are)the well(s): OPermanent or ❑Temporary
By signing this form,1 herehy certify thut the wells)was(were)constructed in accordance
railh 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
r
7.Is this a repair to an existing well: ❑Yes or E]No copy of this record has been provided to,the well owner.
If this is a rtpairt fill out known well construction information and explain the nature of the
repair under 921 remarks section or on the back ofthisJbrm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may alsolattach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface• 505 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dijferem(example-3 at 00'and 2(w100) construction to the following:
i
10.Static water level below top of casing:40 (ft) Division of Water Resources,Information Processing Unit,
If muter 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,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 12 Method of test: RIG 24c.For Water Supply&Injecti In Wells:
PILLS Also submit one copy of this form Iwithin 30 days of completion of
13b.Disinfection type: Amount: 25 well construction to the county health department of the county where
constructed. I
ForF&G W-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013