GW1-2023-00609_Well Construction - GW1_20230105

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS
74.R`ATER`Za7NE$.
FROM TO DESCRIPTION
Well Contractor Name ft. ft. l 1
4519-A ft. ft. P
NC Well Contractor Certification Number t5•00TER,CAgING Poi: iultt-eased;wells.OIIts1NER if;a licable ;' ;i::
FROM TO DiAMF.TF.R I THTCKNF,SS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 84 it. 16 1/4 i" #21 PVC
Company Name 16.YiylY£t2 CASIIVG.OR CUBING' kOthermalclUsed too
21120120513 FROM DIAMETER THICKNESS MATER1.41.
2.Well Construction Permit#: ft. ft. in.
List all applicable uatll permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): '"SCREEN �-
Water Supply Well: FROM TO DIAMETER 11 SLOT SIZE THICKNESS MATERL4L
❑Agricultural ❑Municipal/Public ft. tt. r"•
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft.
7t{.;Gt29UT
❑htdustriaUCotnmercial ❑Residential Water Supply(shared) FROM TO
MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Trri ation 0 ft 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recove ry
Injection Well: ft. ft.
❑Aquifer Recharge ❑GromidwaterRemediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHODfr. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
2UsD2?TLLTN0V6Q altacti:addl i'natsheefs:riiecessa r
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIP71ON color,hardness,soil/rmkri a g=size,etc.)
[]Geothermal(Heating/Cooling Return) ❑Other(ex lain under#21 Remarks) 0 ft. 84 fr. OVER BURDEN
11-18-2022 84 ft 205 fr GRANITE
4.Date Wells)Completed: Well ID# ft. ft.
5a.Well Location:
James Parker �' L" c t'
Facility/Owner Name Facility ID#(if applicable) ft. ft.
251 Tuckaway Ridge Dr
Physical Address,City,and Zip
2I;-REl4fARK5 �,.,.
Henderson 0613829634
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well Geld,one lat/long is sufficient)
N W 11-22-2022
Signature of certi Well Cuntractur Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this form,l hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction 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 known well construction information and explain the nature of the
repair under#11 remarks-section or on the back ofthis farm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.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 onefor•m. 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 rvellc list all deptlu ifdijferent(example-3(4P00'and 2@100) construction to the following:
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
If muler level is above casing.use"+" 1617 Mail Service Cc Inter,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
13a.Yield(gpm) O 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• 20 well construction to the county heal'h Iepartment of the county where
constructed.
Fort GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resuurces Revised August 2013