GW1--04484_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.wATERZONES. , .Al l. .•... ;rsr,., :
FROM TO DESCRIPTION
Well Contractor Name ft. ft. 1
4519-A ft. ft. ,
NC Well Contractor Certification Number :5..OUTER:CASING(formulti-castd Wells)OR LINER(if•i(ppllealile) '•
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 152 ft• 6 1/4 in. #21 PVC
Company Name <J'6.-INNER CASING OR TUDItNC(geo)hermat,etosedIoop),•, `-
W23-0006 FROM 'CO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: L�7 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.
DAgricultural ❑Municipal/Public ft. ft. in.
❑Geothennal(Heating/Cooling Supply) E�JResidential Water Supply ft• ft• in.
PP Y) PPY
❑industrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft• 20 ft• Bentonite Pumped
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑Aquifer Recharge El Groundwater Remediation t9;SAND/GRAVE!,PACK(if npplicahlel- '•
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20r•DttILLiNG.LOG(attach additional.`sbeets if.aecessarv) •.4.'
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness.sotl/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 152 It. OVER BURDEN
4,Date Well(s)Completed: 6/26/2023 Well ID# 152 ft• 405 ft• GRANITE
ft. ft.
5a.Well Location: ft. _
JRO Investments, LLC ft. It. 1 G 4• .:. } al",
s ., s�^
� l +_� ,, .
Facility/Owner Name Facility 1D#(if applicable) -
272 Vineyard Village Dr, Old Fort NC 28762 ft. «: ' JiJ! I ' 2023
Physical Address,City,and Zip c`21.=D✓MARKS•x; ,. - 11.1 ,.. •;) r.
� .3u�rF„
McDowell 066800588108 Well was self certified D
I
1} 8�Dn
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one ladlong is sufficient)
N W nrj8r6---Wili4b.1— 6/27/2023
hnaiureor &'Cem Well ContractorDale
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,i hereby certi/i•that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo • copy of this record has been provided to the well owner.
If this is o repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this font,. 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:405 (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@200'and 2@I DO') construction to the following:
Division of Water Resources,Information Processing Unit,10.Static water level below top of casing: 30 (ft.)
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
i
13a.Yield(gprn) 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-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013