GW1-2022-09447_Well Construction - GW1_20221017

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WELL CONSTRUCTION RECORD For hitemal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS 14 FROM TO M TO -- _DESCRIPTION
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Well Contractor Name ft. ft.
4519-A ft. ft. 1
NC Well Contractor Certification Number FROM 11�1t'CTAOGI DIAMETER'ells:O TFITC KNE SS MATERIAL
ATFRiAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 70 ft- 61/8 1 #21 PVC
Company Name
14 l'Iy1+IERCEtiSIl�G.OR CLtBING 4titllertiial'ci05@d(t?4 `_ ` ..m'
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22100111195 FRONI 1'O DIAMETER in. THICKNESS NIATERIALW
2.Well Construction Permit#: ft. N.
List all applicable will permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): >
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Water Supply Well: FROM I TO DIAMETER SLOT SIZE THICKNESS NIATERL4L
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) [t. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18"GROUT--_....:�..-- METHOD
q;
FRONT TO MATERIALEMPLACEMENT METHOD&AMOUNT
❑Tn; ation 0 et. 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control y
2b:1SI�IGLT GROG atfael.addltlolAalsheets;if�iecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soilt o k type.grain size,etc.)
❑Geothermal(Heating/Cooling Return), ❑Other(explain under#21 Remarks) 0 ft' 70 it OVER BURDEN
8-10-2022 70 ir, 205 it• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft. _
CMH INC.
Facility/Owner Name Facility[DO(if applicable) ft. ft.
103 Two Wheel Dr., Lot 8 ft. ft. OCT L " LLt-
Physical Address,City,and Zip
Henderson 9599778782
County Parcel Identification No.(P1N)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification-
(if well field,one lat/long is sufficient)
Nn AA 9-30-2022
of
Signature ofCci1 Well Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this form,I herehv certify that the wefl(s)was(were)constructed in accordance
With 15A NCAC 02C.0100 or 15A NCAC 02C.0200 N ll Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the well owner.
If this is a repair,fill out knouv well construction information and explain the nature of the
repair under 921 remarks section or on the back of 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 ifnecessary.
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• 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all elepthv iftlijferent(erample:3(d200'and 26t100) construction to the following:
10.Static water level below top of casing: 30 (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 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 Center,Raleigh,NC 27699-1636
Injection ells:
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13a.Yield(gam) 5 Method of test: RIG 24c.For Water Supply&Inj , ,
Also submit one copy of this form,within 30 days of completion of
13b.Disinfection type: Amount: 20
PILLS 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