GW1--07720_Well Construction - GW1_20231122

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT COLLIN BANKS friovATER4ot a � �
FROM TO DESCRIPTION
Well Contractor Name ft. ft. I I
4519-A ft. ft.
NC Well Contractor Certification Number
S15'UUTERIO SiN'G.(foitmuitg as i�YetliMItiONEIY:tiP ap tl al te t Wiz."
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 64 ft• 6 1/4 10 ' in. #21 PVC
a,. .W n r...M F .ai
Company Name ItiIiVNERiAS[IYCw(1RT11B111CAg°e(ithiHmat;cltised-loop}', 4.
390399-2 FROM t0 DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. ! in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. i in.
3.Well Use(check well use): FI SCIpBgN , n . ZW
Water Supply Well: FROM _ TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipallPublic ft. ft. in.
OGeothermal(Heating/Cooling Supply) ©Residential Water Supply(single) ft. ft. in.
� � g PPY) PPY( g
❑Industrial/Commercial ❑Residential Water Supply(shared) �tR GROUP' 6 � �
FROM TO MATERIAL EMPLACEMENT MF.TROD&AMOUNT
❑hrigation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft. I Cap Top with Bentonite Chips
Injection Well: ft. ft. 1
❑Aquifer Recharge ❑Groundwater Remediation t9VSAND/G12AVEIrPAGK4(t:appltclUle)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft, ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.I)RILLING1tia(aCtacltnddrtlunafiheetsrf ieceelin—) . \a
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 0 ft, 64 ft• OVER BURDEN
9-14-2023 64 ft• 605 fr GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: _
ft. ft.
•
RUSSELL CHANDLER ft. ft.
Facility/Owner Name Facility ID('(if applicable)
TBD HY 25/70 MARSHALL, NC 28753 ft. ft. NOV 2 .�, 2Q23
W
I. ft. ,
Physical Address,City,and Zip
2; REM*RICS, 'ne.._. .
MADISON 8880-91-0976 Well Was Self Certified ' a
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 w 9-20-2023
Signature ofCerti Well Contractor I Date
6.is(are)the well(s): ❑�Permanent or OTemporary By signing this firm,I hereby cernf,that the well(s)was(were)constructed in accordance
with 1 SA NCAC.02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No 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 i,
repair under#21 remarks section or on the back rf 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 i'
i
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 di 00'and 24;100) construction to the following:
10.Static water level below top of casing: 300 (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: constmction to the following:
(i•c.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cei ter,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 Method of test: RIG 24c.For Water Supply&Injecti Ilon W ells:
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.
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013