GW1-2022-07730_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:
14.WA1I R'7A1!TES
GARRETT CLYDE BANKS =
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A
°m:OuGASfiYG-.forirtotttcased.yells URzL1IVER:ifia Icabie>
NC Well Connector Certification Number TtR - -
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 177 (t. 61/8 1 '" #21 PVC
Company Name 16:IiVIYER CA$t1VG.0A Pl7HING, "epthermetc(osed too">.
19100112486 FROM 1'O DIAMETER` THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft, in.
List all applicable well permits(i.e.Counnt State,Variance,Injection,etC.l
3.Well Use(check well use): t7..SCRE>LN ..?..�.F-_..:.
Water Supply Well: FROM TO DIAMETER 11 SLOTSIZE THICKNESS I MATER1A1.
❑Agricultural ❑Municipal/Public ft. ft. in•
❑Geothermal(Heating/Cooling Supply) E�IResidential Water Supply(single) t"•1
__,...__ __._... _...._.........._.........._._ ..........
01ndustrial/Commercial ❑Residential Water Supply(shared) 78 GROUT
FROM TO- MATERIAL EMPLACEMENT METHOD&AMOUNT-
❑liTi ation 0 It- 20 ft. Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediatiou 19rSAND/G[tAV:E1 PACK_fifaPolic0lo
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
2b.1S1ffLLING I Ot;.(aftaeti atldttiaiiatslieets ifaiecessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,said o k tv a rain size,etc.)
❑Geothermal Heatin Coohn Return ❑Other(explain under#21 Remarks) 0 ft' 77 ft• OVER BURDEN
07-11-22 77 ft, 165 ft. GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location:
CMH Homes INC
iz r;
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. 2022
^ r
83 Moss Hill Dr ft. ft. I� -
PhysicalAddress,City,andZip 7i:rto y Tip
31.EfEi4TARKS ...
Henderson 9681009775
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 Wn AA 07-15-2022
Sim tare ofCer[r Well Contractor LXL/ Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this fenm.i hereby verri&that the w-ell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consnuction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo ropy of this record has been provided to the well owner.
If this is a repair.fill out knuwn well construction information and expluin the nature of the
repair tender#21 remarky section or on the back of Ibrm. 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 form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 165 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dyferent(example-30a 200'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 wuter 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 die 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 m 15 Method of test- RIG 24c.For Water Supply&Injection Wells:
(gp ) Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: PILLS Amount: 19 well construction to the county health department of the county where
constructed. iE
Form GW-I North Cat ofina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013