GW1-2022-07723_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 1R.M`AIER7AI�TES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A
NC Well Contractor Certification Number 15.OUTER CASING for;iirulh,cased>wells 10
R:LI3VER /cable
FROM TO DIAMF,TFW THTCKNF,SS DIATERTAh
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 56 ft• 6 vs I in.
#21 PVC
Company Name l6,liV1!I£R:CA$t1VG OR FUSING, euthermaF ctpsCtl 1po !s
22100105371 FROM n1AMN;tFX I•HICKNKSS INA•1'FAIAL
2.Well Construction Permit#: ft. ft. in.
List nN applicuble oral permits(i.e.County,State,Yarlance,Injection,etc.)
3.Well Use(check well use): fI. C,REEN
SLOTSI.: „C
Water Supply Well: F
ROMTO DIADTETER, SIZE THICKNESS MATERIAL
❑Agricultural ❑Mumicipal/Public ft. in.'
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) . in•❑Industrial/Commercial ❑Residential Water Supply(shared) TO MATERIAL RMPLACF.MFNT MF.THOiI&.4MOUVT❑TiTi ation 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. tL
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation I9.SAND/GRAB EL PAGK.'if a " 'ilile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology [I Subsidence Control
20.DRIUEIN.01>OC;.attael.ae3dlttaii it dieaof ueeessary`:::
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,solt(o k tv a rain size,etc,)
❑Geothermal(Heating/CoolingReturn ❑Other(explain under#21 Remarks 0 ft• 56 ft. I OVER BURDEN
4.Date Well(s)Completed: 06-6-22 Well ID# 56 ft• 205 ft. GRANITE
ft. ft.
Sa.Well Location: ft. ft. _`
CMH Homes INC ft. ft. .
,__,
Facility/Owner Name Facility ID#(if applicable) Z
ft. ft. � !
12 Two Wheel Dr., Lot 1 ft.
Physical Address,City,and Zip < x
Henderson 9599882644
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 �� 07-04-2022
Signat­L;e_ofCertiM Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary y signing I YY O (were.)B si min•this orm,l hereby tern thin the wells ww• were constructed in accordance
With I5A NCAC 02C.0100 nr 1 to NCAC,02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 3No copy of this record has been provided to the well owner.
If this is a repair,fill ant knuun Hell construction iiifurmatiun and ezrluin the nature of the
repair under#21 remarks section or on the buck iJlhis 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: 1 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 farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi/ferent(example-3(aj200'and 2(a1001 construction to the following:
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
If waer level is above casing.use•'+ ' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cei
rter,Raleigh,NC 27699-1636
i
13a.Yield(gpm)
10 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form Iwithin 30 days of completion of
13b.Disinfection type: Amount: 1 9 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013