GW1-2022-07719_Well Construction - GW1_20220819

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS i4.,3tAIER ..:..�. m ..... :_ _..x_. ... �...
FROM TO DESCRIPTTON
Well Contractor Name ft. ft.
4519-A ft.
NC Well Contractor Certification Number �15.O(Mtkt il1S114G foe attl caeetl:sveits O#t'111V i2 3 s 'licatile ` - 4
FROM TO 1 DIAMETER TMCKNF,SS hIATF.RIAI.
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 177 fi- 16118 C in. #21 1 PVC
Company Name
1d 1iV)`f RCA$1.N, t)RTtJBi1'0 4othermaislvsetFIAii`
22100111109 FRONT DIAMETER THICKNESS NATERIAL
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 SLOTSIZE THICKNESS MATERIAL
ft. ft.❑Agricultural ❑Murnicipal/Public in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) a• ft• m.
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT MF.TROD&.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 Remediation 19.SAND/(3RAr EL PACK::if a eAb1e... .-"..`.?
FRO51 TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
31i10 t ]!100G:uitiieF.aiiiliti"rttlsheefsIdiecessary =:
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION w1or,hardness,soil/rmic tv a Unin size,etc.)
❑Geothermal Heatin Coo6n Return ❑Other(explain under#21 Remarks) 0 rc 77 ft OVER BURDEN
07-14-22 77 rc• 145 ft GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location:
Big Oak Builders LLC ft. ft.
,��,
Facility/Owner Name Facility ID#(if applicable) ft. ft. AUPi
1 —
O Kiwassa Lane, Lot 5 ft. , .�4
Infi�fsc;a.Ii;� : f�•�.,�`.r,3 Ul:il
Physical Address,City,and Zip
�1:3IEMARtfS
Henderson 0600354337
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient)
N W 07-29-2022
Signature of Celts Well Contrctur a Date
6.is(are)the well(s): (aPermanent or ❑Temporary By signing this frnm,I her•ehv certify that the well(,)was(were)constructed in accordance
with 15A NCAC 03C.0100 or 1 SA NCAC 02C.0200 Well Corutmetion Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No copy ofthis record has been provided to the well owner.
If this is a repair,fill out know well construction it!forntatiun and explain the nature of the
repair under#21 remark,,section or on the back ofthis 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,came construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 145 (ft.) 24a. For All Wells: Submit this!form within 30 days of completion of well
For multiple wells list all depths it dilferent(example-3(V00 and 2(a.100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
If muter level is above casing.use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection 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.)
DiAsion of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method
30 oftest: RIG 24c.For Water Supply&InjectionlWells:
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. iI
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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