GW1-2023-02916_Well Construction - GW1_20230420

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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 O
OV DESCRIPTT y...:.,.
Well Contractor Name
4519-A
NC Well Contractor Certification Number 15.(7 U lLrt GASlt+1G formulti caseitieits:ORiGINER'if:a hcabk
FROM TO DiAMF•TRR TRICKNFSS DIATF.RiAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. �70 fi- 6 1/4 'in- #21 PVC
Company Name 16i 11yN£R I'itiStNG OR I UBING COfp Crdidi;t toned 1pti .I
WP ^^-1�� FROM 10 DIAMETER THICKNFSS MATERIAL
2.Well Construction Permit#: LL ft. tt In
List all applicable well permits(i.e.County,Stare,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
tt. ft. in.
❑Agricultural ❑Municipal/Publie
ft, in.
❑Geothermal(Heating/CoolingSupply) OResidential Water SuPP1Y(single)❑Industrial/Commercial ❑Residential Water Supply(shared) FRIRQU 1. TO MATF.RiALEMPLACF.MF.NT METHOD&AMOUNT
1111Ti ation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. rt. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: Ct. ft.
❑A uiferRechar a ❑GrouudwaterRemedietion FROM q g _ SANDIGRA'SFELPAC��>ra %able_...� _ ..::: _.__.:..--
M TO IVIATERI&L EMPLACEMENT METHOD~
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control �.
20;1)R1L11NG13'Uf::a[taeti'additionnlsheets.ifnecessaty::;=` .... . .:.
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type.grain size,etc.)
❑Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) 0 ft. 70 ff• OVER BURDEN
02-28-2023 70 ft• 285 ft• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft.
Scott & Laura Jones ft. ft. �, ; .- <•;',
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
TBD LAdybug Lane ft. ft.
Physical Address,City,and Zip
TRANSYLVAN IA 9526-38-8176-00010U
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification-
(ifwell field,one ladlong is sufficient) 0-
N WnAA 03/10/2023
(7 1�0 r vAvrvo .6 or
Signat of CeIU Well Contractor Dale ure
6.is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with I SA NCAC 02C..0100 or 1 SA NCAC 02C.0200 N ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No copy of tins record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 remarks section or on the back oflhisJbrm. 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 ifnecessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 285 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple%yells list all depths iftlilfcrent(example-i(a�00'and 2(a.1001 construction to the following:
10.Static water level below top of casing: 50 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing.use••+" 1617 Mail.Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection 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(gpm) 3 Method of test: RIG
24c.For Water Supply&Injection Wells:
Also submit one copy of this formlwithin 30 days ofcompletionof
PILLS well construction to the county health department of the county where
13b.Disinfection type: Atnount: 25 � i
constructed.
Forte GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resl urces Revised August 2013