GW1--03614_Well Construction - GW1_20230522

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
1�{y?�1tT••�1�%���. �t�i���n iaA��.`.C"v�'.�..<s'.�\.. .� �v�i�� `i�'�'
GARRETT COLLIN BANKS plifft,
TO DESCRIPTTON
Well Contractor Name 4519-ANC Well Contractor Certification Number iN'4 for tiii w4iiiiA'ells.OK^t 1NEW4, ca,I6A6 eTO DIAMETER THTCKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC 71 ft. 6 1/4 in. #21 PVC
Company Name t6 'KNI;R GASIIYC ORT0B1J10 cci heWif c`ipsed-t4o g � F,.
WP22-153 FROM 'ro DIAMETF.14 'THICKNESS MAIF:RI.AL
2.Well Construction Permit#: ft. ft in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use
17•<5CREEN ��%;�,�.
Water Supply Well: FROM
TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling/Coolin Supply) i�IResidential Water Supply ft. ft. in.
(H g g pp y) pp y(single)
❑IndustriallCommercial ❑Residential Water Supply(shared) FROM1R�GRUUTFROM T
O TO MAT
ERIAL EMPLACEMENT METHOD&4MOUNT
❑ln; ation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery rt. ft. Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation ,ts# e
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
[]Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Teclmology ❑Subsidence Control 4iO'.kDRILUNGs1sUG attaeti,"sdditiUna sheeisifnecessniv`t � R
❑Geothermal(Closed Loop) ❑Tracer FROA[ TO DESCRIPTION color•hardness,soil/mck tv a grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 71 ft. OVER BURDEN
4-26-2023 71 ft. 305 ft. GRANITE
4.Date Well(s)Completed: Well ID# ft. ft. Ff-
5a.Well Location: ft. ft. d 1e
Scott and Laura Jones ft. ft. MAY2 9
Facility/Owner Name Facility ID#(if applicable)
TBD Ladybug Lane Penrose, NC 28766 ft. ft.
Physical Address,City,and Zip
Transylvania 9526-38-8176-000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well Geld,one lat/long is sufficient)
N 05/10/2023
Signature of Cettl Well 6C.."ctor Date
6.is(are)the well(s): ❑�Permanent or ❑Temporary By signing this fen•ni,1 hereh.v terrify that the well(s)Ivas(Isere)constructed in accordance
With 15A NCAC 03C.0100 or 15A NCAC 02C.0200 N'ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy ofthis record has been provided to the well owner.
If this is a repair,fill out knouw uril construction it furmatiun and explain the nature of the
repair under fill remarks•.rection or on the back ofthis 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: 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• 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(exampllc-3 dI 00'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,
If utter level is above casing.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 fortis 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: constmction 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)4 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: Amount: 3� well construction to the county health department of the county where
constructed. ! i
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013