GW1--04481_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:
14.WATER ZONES ,..• .' .,a a ;" a<;" .,6.•; r..... ::
GARRETT COLLIN BANKS FROM _ TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft.
.15:',OUTER:CASING(forinulti-c$ied*ells)OR'LiNER(if ap i Iicable).;t" , , i l
NC Well Contractor Certification Number
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 110 ft• 6 1/4 #21 PVC
Company Name ..16.,1NNER`CASiNG;OR:TUBING(geothertital closed loop)_it a4/,'
SW21-0384 FROM TO DIAMETER THICKNESS MATERIAL
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):
Water Supply Well: _FROM TO DIAMETER SLOT SIZE THICKNESS • MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) R. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METIIOD&AMOUNT
❑Irrigation 0 ft. ft
Non-Water Supply Well: 20 Bentonite Pumped
ft• it. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery ,
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 2<19:?SAND/GRAVELPACK(if applicable).
FROM TO _ MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stonmwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG"(attach additional shietslif necessary).. ,- -s: .:
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 110 ft• OVER BURDEN
06-09-2023Well ID# 110 ft• 405 ft• GRANITE
4.Date Well(s)Completed: ft. H.
5a.Well Location: ft. ft. ,.11 s"'^ " ':r •,..„_
Robert Menzies/Brian Bishop ~"^—`--" •.3' L.
ft. ft.
:i A
Facility/Owner Name Facility ID#(if applicable) ft. ft. JO 1 y 2023
146 Yosemite Falls Rd Old Fart ( i - ft. ft.
Physical Address,City,and Zip Inty s f }to Z i M: f..•.
,,21;"REMARKS'' " _.., , .,. _,. .,/!-"iir �<s, ,.{, if3`-4
McDowell 063800316824 This well was self certified,
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
N WCulAillsti_ 06/13/2023
Signature ofCerti Well Contractor Date
6.Is(are)the well(s): RPermanent or ❑Temporary J. (
By signin8 this firm,I hereby cordh•that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or l5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy oJlhis record has been provided to the well owner.
If this is a repair,Jill out known well construction information and explain the nature of-the
repair under#21 remarks section or on the back of this firm. 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: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water.supple wells ONLY with the stone emtstruclion,van can
submit onefornt. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:405 (ft.) 24a. For All Wells: Submit this fonn within 30 days of completion of well
.For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 (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 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
RIG 24c.For WaterSupply&Injection Wells:
13a.Yield(gpm)4 Method of test:
PILLS 20 Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 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