GW1--04502_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 FROM
PROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. 1 ft.
NC Well Contractor Certification Number r 15:OIT ER CASINTG'(foraunitl-enied;K'ells)•ORItiiNRR(i(npplicable) _
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 70 ft. 6 1/4 in. #21 l PVC
Company Name 6.INNER:CASING OR TURING,(geotheknial closed-lopp)' -y,... ,E, '<.
055-2023-0089 FROM TO _ DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,Stale,Variance,Injection,etc.) R ft. in
3.Well Use(check well use): ^:17.SCREEN ., ,
Water Supply Well: FROM TO , DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothennal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) F$R O,GR 01)T.TO 'MMATEIIAL _ E M_P LACEMENT MET iOD 3cM70U NT
❑Irrigation 0 ft, ft
Non-Water Supply Well: 20 Bentonite Pumped
ft. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation `(9.SAND/GRAVEL`PACK(iftippliObtc}r ,. s
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
DAquifer Test ❑Stonnwater Drainage
R. ft.
❑Experimental Technology ❑Subsidence Control
•20:.DRILLINGLOG-(attach`ad'ditfonalideets:if neeessart ,c :?;
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,gram size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft* 70 ft. OVER BURDEN
06-08-2023Well m# 70 ft. 605 ft. GRANITE
4.Date Well(s)Completed: I. ft. �` _ _
5a.Well Location: ft. ft. [: "' - i ' ^i1*:^ I
Kimzey-Mills LLC �' 1�a 5� '
ft. It.
Facility/OwnerNamc FacilitylDO JULifapplicablc) ft ft. � 1 2023
149 Shep Dr, Mills River
ft ft. jne`vse?'+..►f'iil > •."jPs',Acm tiRa.
Physical Address,City,and Zip 21iREMARKS�a.. . , . .-,i= :7Vil.S.4 8 :7 '0,
Henderson 9621969518 Well Was Self Certfied.
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N ,y 06/09/2023
Signature of Cent Well Contractor Dale
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 1SA NCAC 02C.0100 or/5A 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 a repair,Jill out known well construction information and explain the nature oldie
repair under#21 remarks section or on the back of this farm. 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 1NSTUCTIONS
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 ifdiferent(erample-3@,200'and 2@100'1 construction to the following:
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 80 (ft.)
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For infection 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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 2 Method of test: RIG
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.
II
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013