GW1--03550_Well Construction - GW1_20230519

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I
1.Well Contractor Information:
GARRETT COLLIN BANKS '
FROM TO DESCRTPTION
Well Contractor Name ft. ft.
4519-A ft.
NC Well Contractor Certification Number 15 Otii1 ERF.GA3 N fpr multi kas¢tl S5'eI S'Olt LINEMif" iii:atile k'00ft
I'ROAf TO WAMF•TF.R I I THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt. 64 rt. 6 1/4 i" #21 PVC
Company Name
046;11NKEWCASI Na"61M,U61N( i�ihernta elaRU-4,o'
22120113568 FROM DIAMETER 'THICKNESS MATERIAL
2.Well Construction Permit#: ft. it. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) k ft in
3.Well Use(check well use): 1 ISCRECiy�
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft• ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft• ft. in.
"19 GROUT s `�� �
❑IndustriaUCommercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&.4�iOU.W
❑liri ation 0 ft• 20 ft, Bentonite Pumped
Non-Water Supply Well:
fc. rt. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 69MANOIGRAI E PAGK if a` Ifcali a ':
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery. ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
3tl--KIfRiLLIN0OC�`ta"iiactiaiditiiiondl�SGeefsifmcesse
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock tv a rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 64 ft. OVER BURDEN
5-9-2023 64 ft• 605 ft• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft.
Cheryl Jaroski ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft I
ft. .
377 Turnpike Road Mills River, NC 28759
Physical Address,City,and Zip ZI IlE 1iARK F' x ru x ;;z'?. '
Henderson 9630483834 Well Was Self Certified
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one]at/long is sufficient)
BN `i 5-10-2023
Signature of C-e Well Contractor Date
6.is(are)the well(s): 2Permanent or ❑Temporary By signing this farm.I herehv certify that the ivell(y ivas(nvere)eonsirueled in aceardam•e
ivilh 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well 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.
7f this is a repair,fill out knoirm well construction information and explain the nature of the
repair under 921 remarka section or on the back oJ'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 of wells constructed: construction details. You may also attach additional pages ifnecessary.
For multiple ityce•tion or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 605 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iJ'diJferent(erample-3 dl 00'and 2(a100') construction to the following:
10.Static water level below top of casing: 160 (ft.) Division of Water Resources,Information Processing Unit,
if xuler level is above casing.use•'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24h.For Injection 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: constriction 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) 2 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form(within 30 days of completion of
13b.Disinfection type: Amount: 35 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Euviroument and Natural Resources-Division of Water Resources Revised August 2013