GW1-2022-07716_Well Construction - GW1_20220819

i
WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS FROM P'
3'
O DESCRIPTTO,I
Well Contractor Name ft. ft.
4519-A
NC Well Contractor Certification Number 15.:01i`tlitiCASiNt:.for-, "Itl�caecdwelta i)lt`Ll it'fa Ic"`ahla'., >
FROM TO DIAMRTF.R I THICKNESS I MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 fir. 142 ft 6 1/8 #21 PVC
Company Name td j!11�1£R Ailf!fCs�R fUBIN 40fttermaTStOSCtFtpli `: Via ..:`
22100111776 FROM 10 DIAMETER I'HICKNFSS MATERIAL
2.Well Construction Permit#: rt. tt. j in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc,)
in.
3.Well Use(check well use):
.,,. ...._. .... .. .,. :::.
Water Supply Well: FROMTO DIAniETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal (Heating/Cooling Supply) BResidential Water Supply(sin(single) [t it in.
❑lndustriaUCommercial ❑Residential Water Supply(shared) lst t#O lT-.
FROM TO MATERIAL _ EMPLACEMENT METHOD&AMOUNT
❑h-ri ation 0 ft. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Renrediation
FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery []Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20I)BIGt1G:i" tittaeh"ailtlitloifdsfteetsitriecessa. :,•
❑Geothermal(Closed Loop) ❑Trace[ FROM TO DESCRIPTION color,hardneM soiVrock a rain size,etc.
❑Geothermal Heatin Coohn Return ❑Other(explain under#21 Remarks) 0 it' 42 ft. OVER BURDEN
08-08-22 42 ft 205 ft GRANITE
4.Date Well(s)Completed: Well ID#
5a.Well Location: ft, ft.
CMH INC ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
126 Two Wheel Dr., Lot 7 ft. w ' 9 R -
Physical Address,City,and Zip 2a, EM1TdRKS
Henderson 9599775892
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well Geld,one ladlong is sufficient)
N M-A 08-12-2022
Signature of Certt Well Contractor Date
6.is(are)the well(s): Permanent or ❑Temporary By sibning this form,1 herehv cert(jy that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 nr 1 SA NCAC 02C.0200 11 r11 Consbvc•tion Standwds and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided to the well order.
If this is a repair,fill out known x-ell construction information and explain the nature of the
repair under#21 remarks,section or on the hack 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 jorm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 205 (fit.) 24a. For All Wells: Submit this!form within 30 days of completion of well
For multiple wells list all depths ifdffl rent(example-36(ij200•and 2(a,l00') construction to the following:
10.Static water level below top of casing: 30 00 Division of Water Resources,Information Processing Unit,
I%enter level is above casing.use•'+" 1617 Mail Service Ce Ra
leigh,aleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY: Jln'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.Weil construction method: constriction 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) 6 Method of test: RIG
24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 19 well construction to the county health department of the county where
constructed. ,
Foie GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013