GW1-2023-02917_Well Construction - GW1_20230420

WELL CONSTRUCTION RECORD For Intzmal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT COLLIN BANKS Fa..WrERos .� ....
FR011i TO DESCRTPTTON
Well Contractor Name
4519-A ft.
NC Well Contractor Certification Number �15:t)UTPR'CASEI G for rtv1H case(1eTa .012ft INER tfia hca6le
FRO DIAMF.TF.R THTCKNF,SS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 189 ft• 6 1/4 i" 1 #21 1 PVC
Company Name ;16fi1NNERCASINC.-OR<TUBIIVG- Cotherhlaiclosed-loti '<- -
WP22-160 FROM .1'0 DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well pennies(i.e.County,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 't2.5GREEl�i. `
Water Supply Well: FROM TO DIAMETER SLOT STZE THICKNESS MATERIAL
ft. ft.❑Agricultural ❑Municipal/Public in.
❑Geothermal (Heating/Cooling Supply) EIResidential Water Supply(sin(single) in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT ::z..
FROI41 TO MATF.RTAL EMPLACEMENT MF.TFIOD lr AMOUNT
❑rri ation 0 rc. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ec. rt. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation „19•SAND1[;RAVEL'PACKilaticatile.
❑Aquifer Storage and Recovery El Salinity Barrier FROM ft. O ft.T MATERIAL EMPLACEatE-NT METHOD
❑Aquifer Test ❑Stormwater Drainage
fr. rr.
❑Experimental Technology El Subsidence Control
2tl11R1T LtNGI<11i:a[tiieti additioiialslreetsit:necessa => ---
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hartlness.soiltrock type.grain size,etc.)
❑Geothermal Heating/Coolin Return) ❑Other(explain under#21 Remarks) 0 rc• 89' ft OVER BURDEN
02-28-2023 89 fc• 445 tc• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft.
Blanton, Ashleigh ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. A P K 2 0 M3
Mountain Meadows, Lot 27, 78 Old Mill Rd., Penrose
,Physical Address,City,and Zip t 1 "
fit,tiRNTgRFCS `' .. ..:
TRANSYLVAN IA 9527-01-4107-000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifcation-
(if well field,one ladlong is sufficient)
N W ' . A_ n AA - - 03/10/2023
Signature of Celts Well Coutractor Date
6.is(are)the well(s): OPermanent or []Temporary By signing this form.I herehv certify that the wvell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 11'ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No copy of this record has been provided to the well owner.
If this is a repair.fill out known well construction information and explain the nature of the
repair under 921 remarks section or on the back of this jbrm. 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 some construction,you can
submit one form. ,1 A G SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:445 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiijJ renI(example-3@200'and 2(a.,100) construction to the following:
10.Static water level below,top of casing• 50 (ft,) Division of Water Resources,Information Processing Unit,
Ifwnier level is above easing,use"+•' 1617 Mail Service Center,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
i
13a.Yield(gpm) Method of test- RI G 24c.For Water Supply&Injection[Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type Amount: 25 well construction to the county Health department of the county where
constructed.
Form GW-1 North Cmnlina Department of Environment and Natural Resources—Division of Water Resources Revisal August 2013