GW1-2023-02850_Well Construction - GW1_20230418

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT COLLIN BANKS -
FROM TO DESCRIPTTON
Well Contractor Name ft. ft.
4519-A ft. ft.
15:a3[tTl RCA5ING"formultf casedells.ORLINER ifs hcah[e i;
NC Well Contractor Certification Number FROM TO DiAMF.TF.R TMCKNF,SS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ff. 44 ft- 6 114 #21 PVC
Company Name 3G.tNNERCASINGOR.RING e9thetTltai;closed►oo
MCM-278Q,^`YY FROM 1'O DIANI rF.R THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. in.
List all applicable Hill permils(i.e.County,State,Variance,lnjection,etc.)
ft. ft. in.
3.Well Use(check well use): t?<SCREEN .:a
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS MATERrAAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) OResidential Water Supply(sin(single) ft. ft. tn•
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM I TO "MATERIAL EMPLACEMENT MF.THOD&AMOUNT
❑ire; ation 0 rt. 20 ft- Bentonite Pumped
Non-Water Supply Well:
rf. rt. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge []Groundwater Remediatiml FROM
PI TO MATERIAL EMPLACEMENT 51ETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Storntwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
Z01iRT>C11h1G;'lOG-.att:icl a8ditiurtutsheets:i�iiecessary���...... -;
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soilliwk tv a grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 4 ft' OVER BURDEN
04-11-2023 44 ft- 425 ft- GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location:
Anthony Benett --
ft. ft.
Facility/Owner Name Facility 1D#(ifapplicable) ft. ft.
413 Hominy Bennett ,
Physical Address,City,and Zip
Haywood 8667-53-7203 This well was self certified
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one IaUlong is sufficient)
N W - -- - 6" 04/13/2023
Signature of Cede Well Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary By silming this form,I herebv certify that the uell(s)was(were)constructed in accordance
ivith ISA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the well ouwer.
If this is a repair,fill out knouw well construction in rotation and explain die nature of the
repair under 921 remark-section or on the back ofthisfiirm. 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 also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same constructiom,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:425 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2(a.100') construction to the following:
10.Static water level below top of casing:40 (ft) Division of Water Resources,Information Processing Unit,
If Hnier level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
6.25 24b.For In ection Wells ONLY:: In addition to sending the form to the address in
11.Borehole diameter: (in.) j g
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(gpm) 20 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount• 25 well construction to the county health department of the county where
constructed.
Fomt OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013