GW1--04510_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.WATERZONES, _,
GARRETT COLLIN BANKS FROM TO DESCRIPTION
Well Contractorft. ft. 'Name 1
4519-A ft. ft. '
NC Well Contractor Certification Number 15."OUTER:CASLNG(for multi-caseii tnslls)OR=LiNER(if applicable)'.....!; '
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC - +1 ft. 70 ft, 6 1/4 in' #21 PVC
Company Name 716:iNNERCASJNGORTUBING(geatbermal closed loop) a,
055-2023-0567/055-2023-0366 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.
❑Geothennal(Heating/Cooling Supply) EResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18•GROU t „a
FROM TO 'MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. B
Non-Water Supply Well: 20 Bentonite Pumped
❑Monitoring ❑Recovery ft. ft. Cap Top with Bentonite Chips
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier ft. fit.
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20:,DRILLING LOG(attseh addittonairsheets-ifnecessarv).=_
❑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 fit• 70 ft• OVER BURDEN
06/29/2023 70 fit• 605 ft. GRANITE
4.Date Well(s)Completed: Well ID# ;
ft. ft. [_ _ _ '.'7,
,��
5a.Well Location: ft. It. • f 7 o,^0 1;,, r i'"'
Billy's modular and mobile cont. ft. ft. •
(�
Facility/Owner Name Facility tOP(if applicable) ft. ft. JUL 1 2023
168 Old Memory Lane, Fletcher 28732
Physical Address,City,and Zip + 1 .
-:2L_REMARKs',, , -< �•' -a - v a.$',r;
Henderson 9683178731 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 fat/long is sufficient)
N W 06/30/2023
Signature o1Ceni Well Contractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary / hereby /), )
B,signing this orm,1 co that the well(s)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or 15,1 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or BNo copy of this record has been provided to the well owner.
If this is a repair,fill out Iatovsn well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 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: 605 (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@l00') 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: hi 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 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: 15 well construction to the county health department of the county where
constructed. 1
1
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013