GW1-2023-02014_Well Construction - GW1_20230227

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor information:
GARRETT CLYDE BANKS FR WATER ZONES
OilI TO DESCRIPTION
Well Contractor Name ft. ft. I
4519-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a I eiible)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 1106 ft 6 1/4 il in 421 PVC
Company Name . 16.INNER CASING OR TUBING(geothermal closed-loo '
WP22-134 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable irell perinits(i.e.County,State. Variance,htjection,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) EIResidential Water SuPP1Y(single) f. ft. in.,
❑Industrial/Commercial ❑ FR
Residential Water Supply(shared) GROUT ,
ODt TO aATERIAL EMPLACEMENT METHOD S AMOURT—
C]Irrigation 0 rc. 20 rc• Bentonite Pumped
Non-Water Supply Well:
fit. ft.
❑Monitoring ❑Recovery
Injection Well: fit. fit.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
"
FRO31 TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer•Test ❑Stomlwatcr Drainage
ft. ft.
❑Experimental Technology [--]Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soilfrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) 0 rt 106 rt OVER BURDEN
1-10-2023 106 ft- 505 ft. ! GRANITE
4.Date Well(s)Completed: Well ID#
r.
5a.Well Location:
Jamie Cauble f. ft. FEB ? , 2023
Facility/Owner Name Facility ID#(if applicable) ft. ft.
49 Lem Brooks Lane Brevard, NC 28712 ft. ft. --
v�'u�l�,
Physical Address,City,and Zip 21.REMARKS' i t
Transylvania 8575-63-0833-000 Well Was self Certified
Countv 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)
1-12-2023
N W ra�'Cry K 644%A J
Signature of Ceru Well Contractor Date
6.Is(are)the well(s): PlPermanent or ❑Temporary
Br signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 at-15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy of this record has been provided to the well owner.
//'this is a repair,Jill out known well construction injnrntation and erplain the nature of the
repair under#2l rentarls 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
S.Number ofwells constructed: 1 construction details. You may also attach additional pages ifnecessary.
For uurltiple iigection or non-water sypph•ivells ONLY with the same construction,you can
submit mte.1brin. 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 tfdijjerent(example-3@200'and 2 n 100') construction to the following:
10.Static water level below top of casing: 150 (fit) Division of Water Res Iurces,Information Processing Unit,
//'water level is aboi a caring.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY: in addition to sending the form to the address in
ROTARY 24a above, also submit a copy of Ithis 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
(gP ) 1 RIG 24c.For Water Supply&Injection Wells:
m 13a.Yield Method of test:
Also submit one copy of this form ,within 30 days of completion of
13b.Disinfection type: PILLS Amount: 35 well construction to the county health department of the county where
constructed.
I ,
Foray GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013