GW1--04480_Well Construction - GW1_20230713

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT COLLIN BANKS 14•"``'TER`Z° UMWS ?.Y -mew.—
FROM FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft.
NC Well Contractor Certification Number
AfiNA/iF,EliVASING.(diiiiiiiiilikaIediiiiiifilOglLINEW(iftiftififiliteinliVAM4
FROM TO DIAMETER THICKNESS t\rATF.R[Al.
CLYDE SAWYERS & SON WELL & PUMP INC +1 rt• 120 ft• 61/4 in. #21 Pvc
Company Name ?16:iiNNEI2`ICitSING Ott TUBiNG,(geotherTn£1 closed loop) `Wr
W22-10109 FROM TO DIAMETERTHICKNESS MA'I'F:RIAI.
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): ;zt7 SCREEN.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Publie ft, ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT �.,.,` , r ; a , .. `+� kl "` %"so-' Wr k E
FROM TO MATERIAL 'EMPLACEMENT METHOD&AMOUNT
❑itTigation 0 ft. ft
Non-Water Supply Well: 20 Bentonite Pumped
❑Monitoring ❑Recovery _ ft. ft. Cap Top with Bentonite Chips
Injection Well: ft. ft.
DAquifer Recharge ❑GroundwaterRemediation 119 SAND/GRAVELEAGK°(itappliclble)= = 'x?M m ca
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
DAquifer Test ❑Stonnwater Drainage
ft. ft.
DExperimental Technology ❑Subsidence Control
. 0."DRILLING 1/OOl(a(tacti add)tiaii3l chiefs ifnecessarv)0 .t. . Mz.
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 120 ft• OVER BURDEN
6-13-2023 120 ft. 265 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location:
MICHAEL MASTERMAN ft. ft.
I•` _ :' i �' `T
Facility/Owner Name Facility ID#(if applicable) ft. ft. J I J I j t17�
1085 ARCADIA FALLS WAY OLD FORT, NC 28762 ft. ft.
1 l,L _
Physical Address,City,and Zip 4 ' , ) ! ,.
MCDOWELL 063800329249 Well was self certified -`'�
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certif00/46
(if well field,one lat/long is sufficient)
N 6-14-2023
Signature oontractor Date
6.Is(are)the well(s): l7Permanent or DTemporary By signing this form.1 hereby certify,that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0/00 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or IE1No 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#21 remarks section or on the back of this;/rm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
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: 265 (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 dt 00'and 2(a�100) construction to the following:
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 20 (ft.)
If voter level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6•25 (in.) 24b.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: 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) 1 5 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: 25 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013